On a warm, fall morning in September 1960 an austerely starched and handkerchiefed matron welcomed us to "St. Everywhere 's Diploma School of Nursing." The students - female, middle-class, white, single, 18 year-olds - sat spellbound, ready to journey into the world of Cherry Ames and Sue Barton. Our teachers lectured us about our school's sterling reputation and outstanding performance in "training good nurses." Physicians came to teach us about the miraculous workings of the human body. Like all who have suffered through the pain of an apprenticeship system, we learned by doing; and we practiced five days a week, eight to twelve hours a day, in a hierarchical, medically controlled system. We diligently worked and studied and fretted over our reputed lack of manual dexterity.
Today, 24 years later, we confront sagging jowls, smile lines, and other mid-life crises too numerous to mention. We wondered how our classmates, who are crystallized in our memories as talented, hardworking, and enragingly self-sacrificing, would reflect on their "training" now. We asked whether this Class of '63 would address important issues about women, health, and the nursing profession differently from the perm haired, fadedjeaned women and men about to graduate from today's colleges of nursing.
To answer these and other related questions, we constructed a 49-item, Likert questionnaire which was distributed to the 44 graduates of the Class of 1963. Thirty of these nurses returned the questionnaire for a 68% return rate. A parallel questionnaire was also given to 34 nursing seniors about to graduate from a large, midwestern university program.
Findings, St. Everywhere's
In the Class of '63, 27 of the 30 respondents still identify themselves as nurses and maintain their nursing licensure. However, 21 are currently "retired" (12 of whom say they will never return to nursing); and only three belong to the American Nurses' Association. We asked the Class of '63 for evaluatory judgments about specific aspects of their diploma school preparation. There was consensus that St. Everywhere's had provided excellent preparation for inpatient, physical nursing care, and assisting physicians; good preparation in nursing ethics; fair preparation in therapeutic communication and working with dying patients; and poor preparation for professional or political leadership. The best part of the nursing program for most of the respondents was their "practical, hands-on experience in caring for the sickest patients on the floor"; and, equally important, "living in a dorm together where joy, sorrow, and stress could be shared and life-long friendships established." According to these nurses, the worst parta of training were its "limited scope; the manner in which it encouraged passivity, obsequiousness to physicians, and general dependence; exploitation of students with long work hours; and overwhelming clinical assignments."
The nurses' overall contribution to health care has been significant; they have practiced a total of 313 years in services ranging from traditional specialties such as medical-surgical, psychiatric, pediatrie, or maternal-child nursing, to newer, extended nursing roles such as consultant, researcher, stress counselor, nurse practitioner, and nurse-midwife. When asked to review a list of various nursing roles and select those which would be of personal interest, a majority projected an interest in teaching, home health care with a private caseload of patients, or an independent, private nursing practice.
Fewer than 40% of the Class of '63 believe that continuing nursing education should be mandated. A scant 11% agree that there should be separate licensure for baccalaureate and associate degree or diploma graduates. Only one third of these nurses support the Equal Rights Amendment, while one fourth oppose it.
Given an opportunity to live their lives over, less than one third would re-enter nursing. Instead, the majority would select law, business, journalism, engineering, or a myriad of other professions. Typifying many respondents, one described her future career as, "Anything which will give me more respect, power, and money." A mere 3% would strongly encourage their children to enter nursing and 50% would discourage their children from doing so. However, if their children were insistent about becoming nurses, their mothers would overwhelmingly recommend baccalaureate nursing programs.
A few of the nurses defended the type of nursing education we had received, and recommended it continue as a viable option for current students; they also complained that modern nurses are becoming too assertive. "In my experience working with many physicians, I find many are threatened by RNs who come on strong .... The younger doctors (i.e., physicians) rely heavily on their RNs to make decisions and act on them. But with more education, some RNs are getting pushy and even the younger physicians complain." Several of the respondents felt the Class of '63 cared about patients, where the modern nurse does not.
The Class of '63 seemed to be fairly evenly divided over their prognoses concerning nursing's future. There were those who claimed nothing could ever convince them to return to nursing - "The hours and pay are terrible; it's hard work which requires stamina and patience." Many decried nursing's professional inertia. "I sometimes wonder whether or not nursing will ever get its act together to decide on one basic educational format, be able to enter into collégial relationships with other health professionals, to be truly professional."
Others, a bit more optimistic, wrote: "Today's women (and men) beginning a nursing program are probably going to be more dedicated to nursing than we were ..." "These students have probably thought through many more career choices before deciding on nursing . . ." "It is no longer just something to do until you meet the right man to take you away from all this." Another emphasized this general optimism when she wrote, "I returned to the hospital six months ago after a 16-year absence. I was terrified and overwhelmed for almost three months even though I had a refresher course. Things are much better now although I have a lot to catch up on yet. But I love it!"
Findings, Midwestern University
Of the 34 university nursing seniors completing the questionnaire, all were female and the average age was 24. Three of the students already had bachelor's degrees in psychology, biology, or teaching - one had a doctorate in education. The University class of '84 rated their basic nursing preparation differently from the diploma class of '63, but only in certain respects. There was more similarity than the researchers originally anticipated. Although only 33% agreed that they had received excellent preparation in inpatient physical nursing care (the remainder felt their preparation in this area was good or fair), 60% believed they had good training in assisting physicians. Eighty percent said they received excellent or good preparation in nursing ethics in this non-sectarian nursing program. There was consensus that their classes in therapeutic communication were excellent (50%) to good (50%), as were those in conducting physical exams and supporting patients through life crises. The majority of the class of '84 felt they were only fairly or poorly prepared to deal with dying patients, organize political activity, or be an ANA or NLN officer. Forty-four percent felt their preparation to manage a staff of nurses was only fair and 12% felt their preparation in this area was poor. This is similar to the class of '63.
These soon-to-be graduates described the best parts of their education as a "Solid theoretical background"; "push for leadership and the nursing profession"; "the quality of instructors"; "being exposed to various races, lifestyles, and ethnic backgrounds"; and "clinical experiences"; and, like their counterparts of long ago, "The great friends I have made here." They described their worst learning experiences as "Inadequate or insensitive clinical instructors; overload of classes; too much stress, and immense amounts of paper work."
These nurses' interest in various, expanded nursing roles was similar to that of the class of '63; they also thought they would enjoy working in home-health-care with a caseload of patients; teaching nursing students; or having a private nursing practice. Unique, however, was the large number of young nurses who would like to be part of a nursing research team or work as a clinical nurse specialist.
Fifty-three percent thought nurses had a major responsibility (41%, some responsibility) to improve our country's health care. In order to do this, the young nurses agreed with the middle-aged ones that nurses might have health programs on a radio or television, initiate or direct a consumer health movement, or carry a caseload of home health care patients. Although none of these neophytes believed these roles were inappropriate for nurses (as some in the class of 1963 did), they were similar to their "foremothers" in not wishing to adopt these roles for themselves. Their own recommendations for nursing approaches to widespread and improved public health were varied ("hold consumerhealth awareness seminars and public health community programs") and supportive of organ ized nursing movements ("Join and lead in the ANA; Run for political office"). They did not, however, offer recommendations for whistle-blowing, government regulations, or nurse-run clinics, as did their older colleagues.
Unlike the Class of '63, they felt nursing continuing education should be mandatory (26% strongly agreed, 68% agreed); and that there should be separate licensure for baccalaureate and associate degree or diploma nurses (35% strongly agreed, 44% agreed). Ninety percent support the Equal Rights Amendment.
Forty-seven percent say they would encourage their children to enter the nursing profession; and 76% say they would, if they had it to do over, re-enter the nursing program today. Their choices of alternate careers varied and (from the eyes of their elders) seemed more romantic and artistic and less jaded than their older counterparts. They thought they might want to be a gourmet cook in an exclusive restaurant or a travel agent; there were several singers and performers, a composer, a ballet dancer, a member of the symphony orchestra, a famous journalist, and a renowned actress.
In elaborating on how they perceived themselves to be different from the typical practicing nurse, the young nurses said they were "more heterogeneous, liberal, intellectual, professional, assertive, politically-aware, independent, and idealistic." One hoped that "My idealism is not atypical; but I have found the average floor nurse is terribly apathetic." From the same aspect, another wrote, "I think we all hold on to the belief that what we do does make a difference."
The Class of '84 's response to the effect of nursing's being a female profession was an instant-replay of their predecessors. They noted nursing's inadequate salary, respect, and status; being subservient to male physicians; and not being given recognition as a profession. However, similar to the class of 1SS, they also perceive that their predominately female profession has helped to humanize a technical, competitive, capitalistic, and computerized health-care system.
The classes of '63 and '84 present some interesting contrasts. Of course, these differences can be attributed to many facets in addition to university versus diploma nursing education. Two decades have passed. A social revolution concerning women's roles has occurred (Bernstein, 1979; Hardin & Skerrett, 1981) and beginning practitioners presumably reflect strikingly different self-perceptions and role reflections than more seasoned professionals.
Without positing the causes, we see some of the contrasts between these nursing generations as being differences in selfperception, role orientation, and professional identification. Considering self-perception, it appears that the Class of '63 is still ambivalent or in the transition stage from being their mothers' daughters to being their own persons (Friday, 1977; Hardin & Skerrett, 1981; Menaker, 1979). While they loathe the passivity and dependence toward which they believe they were socialized, they remain, nevertheless, convinced that caring and concern are primarily female qualities and that they, therefore, have humanized health care and elevated nursing to an art form. Moreover, there are clues which reveal lingering doubts about the efficacy and propriety of RNs being too assertive, especially if this is an annoyance to physicians. Many of the older respondents seemed aware of this ambivalence (Hardin & Benton, 1984); and agreed that this next generation of nurses is more intellectual, independent, and assertive. (They are three times more likely to support the Equal Rights Amendment than their older counterparts. )
The debate over whether nurses two decades ago "cared" about their patients more than our modern Nightingales do is rather senseless. Caring and knowledge are not opposing concepts; occasionally, the older nurses' remarks seemed to insinuate that they are. It might be more productive to question and challenge the organization of inpatient health care which often produces frenzied caregivers who dash from one technical task to another. Under these circumstances, nurses' amount of caring is relatively meaningless.
As for role orientation, the desire on both the part of the '63 and '84 graduates to be involved with home-health care, private practice, and nursing clinics reveals a leaning toward autonomous practice. Indeed, findings of research on private nurse psychotherapists (Hardin & Durham, 1984) showed that hospitals were most frustrating to nurse specialists and the search for autonomy was a prime motivating factor for nurses to establish their own practices. It may be that nurses do not wish to get out of nursing as much as they wish to get out of hospitals.
The baccalaureate graduates revealed a more professional identification in seeking continuing education, agreeing that continuing education should be mandatory for licensure, joining in professional nursing organizations, and subscribing to professional journals. This coincides with findings of other nurse educators (Mannette, 1982; Whelan, 1984) who report increased professionalism as a significant trait of baccalaureate registered nurses.
The similarities between these two groups are as interesting as their differences. For both groups, early friendships are invaluable in sustaining them through the stresses of nursing education; and for the older group, such sentiments have remained over the years. Both groups reflect intensely difficult problems with clinical education which have plagued nursing in the past and may continue to do so. Neither group of students was prepared well to work with dying patients (who may compose a majority of hospitalized inpatients in the near future). The baccalaureate nurses seemed especially reticent concerning their physical skills. This deficit is one which cannot continue to be ignored. As a patient in a recent doctoral research survey remarked: "I did not care about her (the nurse's) terrible personality - she got my tube down and that was all I wanted then" (Anderson, 1984).
In terms of nurses' roles and responsibilities, the '84 class more clearly articulates independent knowledge and judgment and a strong sense of responsibility to be patients' advocates, not only by caring about them, but by teaching them and safeguarding their process through treatment.
Finally, it is rather disheartening that only 30% of the Class of '63 is still practicing and that 40% will never return to practice their profession. Even worse, only 3% would encourage and 50% discourage their children from entering the field. We must question whether it is because of bitterness over their training or early nursing experiences; or because of a hopelessness that clinical nursing situations will ever improve. In some respects, the class of 1963 may feel shortchanged. They have faced an era when not only nursing has changed dramatically, but so also have women's roles. Now their demand for money, status, and power may reflect their having given too much for too long to too many.
It is our hope that most new graduates will reflect the optimism of the '84 graduate who believed that what she did made a difference; and that this optimism will become unified to define nursing practice in such a way that the class of '84 will complete questionnaires which reflect involvement, continued optimism, and an organized and dynamic nursing profession in 2006!
- Anderson, N. (1984). Patients' experiences of exclusion and confirmation in a hospital setting. Unpublished Doctoral Dissertation, University of Illinois at Chicago.
- Berstein, D. (1979). Female identity synthesis. In A. Roland &. B. Harris iEds.), Career and motherhood: Struggles for a new identity. New York: Human Services Press.
- Foley, K-, Hardin, S.B., & Skerrett, K. (1981). The dual career nurse: Working and mothering. Point of View, 18, 17-19.
- Friday, N. (1977). My mother, my self New York: Delacorte Press.
- Hardin, S.B. & Benton, D.W. (1984). Fish or fowl: Nursing's ambivalence toward its symbols. Journal of Nursing Education, 23, 164-167.
- Hardin, S.B. & Skerrett, K. (1981). Counseling working mothers. Journal of Nurse Midwifery, 26, 19-25.
- Hardin, S.B. & Durham, J. (1985). The structure, process, and effectiveness of nurse psychotherapy. Journal of Psychosocial Nursing and Mental Health Services, 23, 9-15.
- Manette, R- (1982). Attitudes toward professional nursing behaviors held by R.N. students. The School of Nursing of Columbia University, 2, 6.
- Menaker, E. (1979). Some inner conflicts of women in a changing society. In A. Roland & B. Harris (Eds.), Career and motherhood: Struggles for a new identity. New York: Human Services Press.
- Whelan. E.G. (1984). Role-orientation change among R.N.'s in an upper-division level baccalaureate program. Journal of Nursing Education, 23, 151-156.