During the past 20 years, major changes have occurred in nursing education. Perhaps the primary change has been the decreasing number of hospital-based diploma programs and the increase in the number of associate degree and baccalaureate degree programs. Much of the impetus behind this trend has been provided by the 1965 ANA position paper on nursing education. In that paper the American Nurses' Association recommended that all education for those licensed to practice nursing take place in institutions of higher education, that minimum preparation for beginning professional nursing practice be baccalaureate education in nursing, and that minimum preparation for beginning technical nursing practice be associate degree education in nursing.
In June 1970, the recommendations of the National Commission for the Study of Nursing and Nursing Education were published (Lysaught, 1970). Regarding nursing education, this commission states: "We believe that the future pattern of nursing education should be developed within the framework of our institutions for higher education" (p. 107). This commission further proposed that hospital schools of nursing move toward degree granting power by ainterinstitutional arrangements, and that junior and senior collegiate institutions cooperatively develop programs and curricula that will preserve the integrity of these institutions and their aims while facilitating the social and professional mobility of the nursing student.
In spite of movements toward collegiate nursing education, a number of problems still exist in our "system" of nursing education. Lack of articulation between nursing educational programs is making upward career mobility a frustrating experience for many students. Movement from one level to another is sometimes impossible without beginning all over and repeating content already covered in a previous program. With educators divided into rival camps, students are often caught in the middle, victims of a profession beset by educational problems especially in the area of articulation. Bullough (1972) compares nursing to a small Midwestern steel town which because of an uncertain economic cycle has difficulty making commitments to long term civic improvements. Consequently, a pollution-choked river runs through the city which provides a limited number of bridges. Bullough describes an incident which occurred in such a town:
On our second day there we went out looking for an apartment and became hopelessly lost in a lonely industrial section of the city. The only person we could find to ask for directions was a weary looking old man. We told him the address we were looking for and he looked puzzled, so we passed him the scrap of paper which had the address written on it. He studied the numbers for some time and turned the paper over to ponder the back of it. Then he shook his head and said, "You can't get there from here" p. 4).
Much like travel within this town, there still exist dead-end avenues and blocked access routes within the nursing profession and educational system. Because hospital schools have not been able to issue academic credit, Bullough compares them to a primitive barter economy which is suddenly forced to trade with a money economy. The collegiate programs, recognizing college credits, represent the formal monetary system and have been able to exploit the more primitive härterer by insisting that because they have no coins (college credits) their goods (education) are worthless. Many diploma schools have arranged for non-nursing courses to be taught on university campuses for college credit. This has eased the dilemma of some students who choose to pursue a baccalaureate degree in nursing.
As diploma programs decrease and associate degree programs increase, we must be cautious not to put the associate degree student in the same bargaining situation. Lysaught (1974) suggests reconstructing our baccalaureate programs so as to ease the transition of RNs into upper-class levels, providing courses challenging and new to these students, and providing greater opportunity for student selection of learning alternatives.
The results of a study, conducted by the state of Missouri in 1976, revealed that only 64% of the need for baccalaureate educated nurses was met in the St. Louis metropolitan area. In light of the national trends and local statistics, Maryville College decided to develop an RN transfer program to meet these needs.
Development of the Program
Several years ago, the nursing faculty decided to work toward the goal of providing the RN student with the opportunity to obtain a BSN degree without having to repeat content and experiences. They wanted to provide the RN student with a flexible, individualized program which built upon previous knowledge and skills. It was believed that this program could be developed with inherent quality and could meet NLN standards for accreditation. It was also believed that this program could broaden and expand the RNs education to meet contemporary and future health care needs.
The basic assumptions made prior to the development of the curriculum were: 1) there is a core of nursing knowledge/skills that is basic to nursing preparation at the lower division level; and 2) there is a core of nursing knowledge/skills which does not duplicate basic nursing preparation but which builds on that foundation and provides opportunity to expand and extend nursing knowledge and competencies. Another premise underlying the curriculum construction was that nursing content builds on and integrates the liberal arts into the curriculum.
Inherent in the philosophy of the program is the concept of the student as an adult learner, who is capable of self-direction, possessing a reservoir of experience that is a resource for learning, a readiness to learn, and a need for immediacy of application. The curriculum was designed incorporating these concepts. The faculty identifies and capitalizes on the student's background and experience. The students also are involved in the planning and implementation of their own learning experiences.
Decisions were made as to the competencies that would be expected of the graduates of the program. The faculty believes that the graduate with a baccalaureate degree should be able to utilize the nursing process not only to support but to promote adaptation in episodic and distributive settings with individuals, families, and groups in our society. The graduate should be able to synthesize knowledge from the physical and behavioral sciences as well as the humanities and fine arts, and to utilize this knowledge as a source for making nursing practice decisions. The research process should be used by the graduate as a basis for improving the quality of patient care and to assist clients to adapt to actual or potential health problems. The graduate should also be able to demonstrate leadership ability and affect change in a variety of practice settings. Awareness of internal values, strengths, and weaknesses is the basis for initiating change for self improvement and professional/personal development. Knowledge of present and future factors affecting the health care delivery system prepares the graduate to assume expanding nursing roles.
An adaptation theory was selected by the faculty for the conceptual framework to provide organization and unity to the curriculum design (Roy, 1976). The design of the curriculum builds on knowledge and skills at the lower division of nursing practice, integrates key concepts between areas of study, and is organized in a sequential simple to complex order of succession. Content is taught regarding adaptation of the individual first, the family next, and gradually in relation to adaptation of groups and systems in the community and society.
Integrative concepts were selected from lower division nursing content that would be expanded in breadth and depth at the upper division level. The first of these concepts is man. Man is viewed as a biopsycho-socio-cultural being who is constantly adapting to stressors in the environment. The goal of nursing, therefore, is to promote man's adaptation toward optimal health.
The concept of man is considered not only as an individual but is expanded to include family, community, and society. Learning experiences focus on the role of the nurse in promoting adaptation with individual families and groups in community settings. Content and experiences focus on a psychosocial assessment of man and, determining multicausal factors influencing behavior, the concepts of the nursing process are expanded to determine innovative and probable solutions to complex health care problems. Through the ongoing process of evaluation, the student assumes accountability.
Communication is viewed as a vital component of the nursing process and is essential to the nurse-client interpersonal relationship and to collaboration with other members of the health team. Experience is provided in developing the student's selfawareness, sensitivity to other's needs, and communication with families and groups in the community.
The assumption made by the faculty was that lower division nursing curricula traditionally focus on intervention in common, recurring illnesses where there are usually predictable outcomes. It was decided that the focus in the upper division nursing curriculum should be on wellness, health maintenance and health promotion, rather than illness. The curriculum provides experience in the practice of nursing where continuity of care, prevention of illness and promotion of adaptation toward higher levels of wellness are stressed. Health promotion is integrated with the concept of teaching-learning and is viewed as a way to affect change. In the senior year the student puts into practice concepts of health promotion in both the acute care and community setting with various client populations.
Leadership skills are broadened to include comprehensive assessment and creative problem solving to improve nursing care in a variety of nursing practice settings. Integral to the development of leadership skills is the ability to be selfdirected and secure in expanding nursing roles in episodic and distributive settings with individuals and groups in all phases of the health-illness continuum.
There are two integrative threads that are introduced in the upper division nursing curriculum as new constructs - research and change. Research is viewed as the basis for change in nursing practice and for decision making. Students have the opportunity to develop research skills and participate in the various components of the research process. Change is viewed as a necessary adaptation to a shift in the environment. Change evolves out of effective leadership in problem solving. Strategies of change are utilized by students in acute care as well as community settings and include collaboration efforts with other health professionals to clarify, interpret, and improve care.
Needs of the Student RN
Students enter RN transfer programs with varied backgrounds in education and experience. Those seeking a bachelor of science degree in nursing range from the newly graduated associate degree nurse having less than one year of experience to the diploma-prepared nurse having 20 years of work experience. An RN transfer program must provide for the learning needs of students along the continuum of education and experience.
Incoming students enrolled in an RN transfer program are often working at least part time, and many need to continue working while attending school. Nurses are employed on all three shifts, and this creates the need for scheduling to accommodate individual work schedules.
The faculty decided that flexibility was of utmost importance in arranging class schedules. Thus all upper division nursing classes are taught in day and evening sections. The same content is taught in each section allowing the student to attend either section. The student has the option to choose day or evening clinical experiences in all but one clinical course. A traditional community health experience is offered on a variety of days, thus maintaining a degree of flexibility. In addition, the required cognate college courses have day and evening options.
Since the students have diverse nursing experiences, validating current nursing knowledge and skills is a prerequisite for admission to the upper division nursing major. This is accomplished by administering comprehensive nursing examinations. These teacher-made examinations are based upon terminal objectives for the associate degree student and are given in each of the four major nursing areas. In addition to successfully completing the four written examinations, the student is required to demonstrate basic nursing competencies in a simulated laboratory examination. Upon passing these five examinations, the student earns lower division nursing credits. Thus the student's lower division nursing knowledge and skills are validated without the student repeating basic nursing courses.
Effort is made to enhance the individual's growth in a chosen area of clinical interest and add to the student's general knowledge base. This is accomplished by individualizing some aspects of the program. One of these is the Professional Development Plan, a unique process of socialization integrated into the curriculum. Upon entry into the upper division nursing courses, students complete a comprehensive assessment of their education and practice experience, determine problems and areas of learning for self-improvement in the nursing role, and develop short-term and long-term objectives. The student plans with a faculty member ways in which the objectives can be operationalized through selection of clients and experience in an area of concentration of individual nursing interest. In addition, nursing courses are designed to encourage the student to share individual experiences through class discussions and projects. The final clinical course is designed specifically for the student to practice in a clinical area of interest.
Problems Inherent in an RN Transfer Program
The socialization process that occurs during the RN's return to school presents new conflicts and role changes that foster potential problems. Due to experiences of the nurse in a work setting, adjustment to a school setting is usually more complex for the returning RN than for the generic nursing student. As pointed out by Muzio and Ohashi (1979), the generic student is experiencing "professional role development while the RN student is experiencing professional role change" (p. 531). Prior knowledge and behavior patterns may interfere with new learning, attitudes, values and concepts which must be incorporated into the RN's current belief system.
Any number of factors can influence the student's perception of this new role causing the student to react with frustration, anger and defensive behavior. One factor may be prior nursing experiences. The registered nurse has been socialized as a "professional nurse" and may have practiced nursing for many years. It may be difficult for her to recognize that an increased scope of nursing knowledge is available. It is essential for the student to understand that prior experience and knowledge is important, and provides a sound base upon which expansion of nursing knowledge may be built.
Another factor may be a fear of inadequacy or failure. If the student is a nurse without college experience, she may be unfamiliar with academic procedures and expectations. Coming from a structured environment, the student may experience stress in attempting to perform in an environment that values self-direction. This fear may be converted to antagonism toward faculty or administrators.
The RN student may also be functioning in multiple roles which provide the basis for potential problems. In addition to the new role of student, she may also be carrying out the role of wife, parent, breadwinner, and practicing nurse. Demands and responsibilities of these roles create increased stress, and force her to prioritize and balance these roles within her lifestyle. As a result of the complexity, it may become apparent that the student's expectations are unrealistic as she attempts to work, care for a family, and pursue a baccalaureate degree.
A challenge to the faculty of the program serving the RN student is to offer content appropriate to the students at a higher level of learning which is not repetitive of previous education. The aim of the faculty in curriculum planning is to present courses and content that continue where the basic nursing education ends, and expand into areas of nursing and health care not previously experienced.
Methods of teaching also need to be altered in view of student characteristics. Faculty need to challenge these students with work that requires high level cognitive thought patterns such as analysis and synthesis (Muzio & Ohashi, 1979). Learning experiences within nursing courses should incorporate and emphasize critical thinking. The student, who is also a practicing nurse, brings multiple and varied experiences to the classroom. These can be utilized to promote discussion, problem solving, and planning for nursing intervention. Seminars promote vicarious learning through sharing of clinical experiences and immediate utilization of new knowledge provides an effective method of learning to the RN student.
Inherent in flexible scheduling is the difficulty in securing clinical facilities which provide evening options. Providing clinical experiences to meet individual student learning needs is also a challenge to nursing educators. Faculty time and workload is obviously more difficult due to repetition of class presentations as well as scheduling of clinical time.
A BSN program for RNs fulfills a definite need both in the community and for the professional development of its students. As long as RNs are being educated in diploma and associate degree programs, the demand for a BSN for these graduates will continue. Colleges and universities can offer programs that provide quality nursing education and meet the unique needs of the RN student. These needs can be met by introducing individualization and flexibility without compromising the quality of baccalaureate nursing education.
- Bullough, B. (1972). You can't get there from here: Articulation in nursing education. Journal of Nursing Education, 22(4),4-10.
- Lysaught, J.P. (1970). An abstract for action. New York: McGraw-Hill.
- Lysaught, J.P. (1974). Action in nursing: Progress in professional purpose. New York: McGraw-Hill.
- Roy, Sr. C. (1976). Introduction to nursing: An adaptation model. Englewood Cliffs, NJ. Prentice-Hall.
- Muzio, L.G., & Ohashi, J.P. (1979). The RN student - Unique characteristics, unique needs. Nursing Outlook, 8, 528-532.