Journal of Nursing Education

Associate Degree Nursing and Curriculum Revolution II

Verle Waters, MA, RN

Abstract

The curriculum revolution causes me to look backward as well as forward. Beginning in 1952, I was part of a revolutionary cell group - a small, growing band of teachers in the experimental and new associate degree nursing (ADN) programs. We knew we were overthrowing deeply embedded beliefs and practices; our ideas and activities met with disbelief and sometimes hostility, and we were zealous and non-conforming. It was thrilling work.

Today, the revolutionary curriculum and teaching practices introduced in those programs are conventional and middle-of-the-road. What, then, in the "new" curriculum revolution, informs associate degree education? Since in the days of zeal, associate degree nursing seemed to point the way; has it found the way? To state the question differently, do the reforms called for in the rhetoric of the curriculum revolution apply to BS and MS programs only, or is there a mandate for change in the ADN programs as well?

Conferences and literature about the curriculum revolution have primarily addressed professional education. There is, in fact, some suggestion that the revolution might be limited to the baccalaureate and master's curriculum in the argument that adherence to the Tyler model of curriculum development is appropriate to technical training, but not professional education. Bevis makes the same point in predicting that baccalaureate and master's programs will be most affected by new ways of perceiving curriculum (Bevis, 1988). If .that is the case, are those of us in ADN circles going to define this as the other's revolution, take up a spectator role, and limit participation to an occasional bit of kibbitzing? I believe otherwise. The mandate for change, indeed, the need for the spirit and energy of change is as compelling for ADN education as for any other program type.

The new voices calling for all-embracing change in the education of professional practitioners have prompted me to think about the past as well as the future of the associate degree curriculum, and to reflect on the shifts and turns in its development since 1952. The four decades of the existence of associate degree nursing, from the post World War II era to the cusp of the new century, have been decades of economic and social transfiguration in America. In one sense, the structure and intent of the curriculum has been remarkably stable. But in very important ways, the events of the past 38 years have had a teUinginfluence on the values and attitudes embedded in the curriculum.

In 1952, the first two programs were established as frank experiments; by 1960 there were more than 60. The curricula, the students, and the learning activities were dramatically unlike other nursing programs. Innovation characterized every aspect of the program except its purpose, which was to prepare a registered nurse. The curriculum structure then in standard use was diseasecentered, and courses carried titles representing geographic units in the hospital: medical nursing, orthopedic nursing, EENT, ER, central supply, and so on. In the new ADN programs, nursing faculty in each college were expected to design curricula that fit educational patterns of career education at the college, and develop nursing courses around broad concepts or fields comprising nursing knowledge. Research by Abdellah on the problems experienced by hospitalized patients that nurses responded to became an immediate frame of reference for patient-centered teaching in the new programs (Matheney, 1964). Experimenting with patient problems as the format of instruction led to the use of pre- and postconferences in clinical education, and to the initiation of new clinical practice records for students that engaged them in the steps of identifying and addressing patient problems.

The students themselves induced a…

The curriculum revolution causes me to look backward as well as forward. Beginning in 1952, I was part of a revolutionary cell group - a small, growing band of teachers in the experimental and new associate degree nursing (ADN) programs. We knew we were overthrowing deeply embedded beliefs and practices; our ideas and activities met with disbelief and sometimes hostility, and we were zealous and non-conforming. It was thrilling work.

Today, the revolutionary curriculum and teaching practices introduced in those programs are conventional and middle-of-the-road. What, then, in the "new" curriculum revolution, informs associate degree education? Since in the days of zeal, associate degree nursing seemed to point the way; has it found the way? To state the question differently, do the reforms called for in the rhetoric of the curriculum revolution apply to BS and MS programs only, or is there a mandate for change in the ADN programs as well?

Conferences and literature about the curriculum revolution have primarily addressed professional education. There is, in fact, some suggestion that the revolution might be limited to the baccalaureate and master's curriculum in the argument that adherence to the Tyler model of curriculum development is appropriate to technical training, but not professional education. Bevis makes the same point in predicting that baccalaureate and master's programs will be most affected by new ways of perceiving curriculum (Bevis, 1988). If .that is the case, are those of us in ADN circles going to define this as the other's revolution, take up a spectator role, and limit participation to an occasional bit of kibbitzing? I believe otherwise. The mandate for change, indeed, the need for the spirit and energy of change is as compelling for ADN education as for any other program type.

The new voices calling for all-embracing change in the education of professional practitioners have prompted me to think about the past as well as the future of the associate degree curriculum, and to reflect on the shifts and turns in its development since 1952. The four decades of the existence of associate degree nursing, from the post World War II era to the cusp of the new century, have been decades of economic and social transfiguration in America. In one sense, the structure and intent of the curriculum has been remarkably stable. But in very important ways, the events of the past 38 years have had a teUinginfluence on the values and attitudes embedded in the curriculum.

In 1952, the first two programs were established as frank experiments; by 1960 there were more than 60. The curricula, the students, and the learning activities were dramatically unlike other nursing programs. Innovation characterized every aspect of the program except its purpose, which was to prepare a registered nurse. The curriculum structure then in standard use was diseasecentered, and courses carried titles representing geographic units in the hospital: medical nursing, orthopedic nursing, EENT, ER, central supply, and so on. In the new ADN programs, nursing faculty in each college were expected to design curricula that fit educational patterns of career education at the college, and develop nursing courses around broad concepts or fields comprising nursing knowledge. Research by Abdellah on the problems experienced by hospitalized patients that nurses responded to became an immediate frame of reference for patient-centered teaching in the new programs (Matheney, 1964). Experimenting with patient problems as the format of instruction led to the use of pre- and postconferences in clinical education, and to the initiation of new clinical practice records for students that engaged them in the steps of identifying and addressing patient problems.

The students themselves induced a revisionist attitude in teacWng-learning practices. No nursing teacher had before this time encountered the challenge of such diversity. In the pilot ADN programs, students ranged in age from 16 to 59 years and included students who were veterans, were married or divorced, and who were parents. They lived at home rather than a dormitory, and commuted to classes (Montag, 1959). A student group so different in all respects except the desire to be a nurse was not unexpected; indeed, the experiment assumed the attraction into nursing of a previously untapped student group (Montag, 1959). But the dramatic change created for new faculty in the new programs a momentary clean slate where none of the conventional wisdom about nurse's training applied, including the usual relationships between students and teachers. The convention of students addressing a teacher as Miss Expert could be abandoned when students were suddenly older and more life-experienced. The playing field was leveled, and an egalitarian approach emerged whereby students and teachers jointly sought ways to meet the goals both had in mind.

There was a brazen creativity and looseness in the new programs that was stunning. Faculty from the pilot programs came together for summer workshops under the aegis of the Cooperative Research Project in Junior and Community College Education for Nursing to discuss the novel, broad-brush nursing courses, to share results of new teaching-learning methods and activities, and to swap stories of encounters with the unbelievers. Topics such as pharmacology and nutrition were not taught separately, but integrated throughout; we named them "threads" and explored the many ways they might be woven into the program of study.

That curriculum revolution was a success. The programs as a form of nursing education would experience high replication with a remarkable growth pattern in the next two decades. They were a success, too, from the stand-point of initiating curriculum and teaching practices that soon became the norm in nursing education. Even the now-questioned insistence on behavioral objectives and the use of Mager's little volume as a rulebook can be traced to the workshops and conferences offered for new ADN faculty at the time of the Mager publication in 1962.

The 1960s decade was one of expansion for ADN education. On the average, 38 new ADN programs opened each year during the decade, or three each month. The Surgeon General's Consultant Group in Nursing recommended in 1963 that by 1970 there be a 445% increase in ADN graduations; there was, in fact, a 722% increase between 1963 and 1970 (American Nurse's Association [ANA], 1980-1981).

The major issue facing ADN education during the '60s decade was finding faculty, and searching for ways to extend existing faculty resources. Large grants from both philanthropic and federal sources were devoted to teacher preparation, and new teaching methodology to extend faculty resources. With extramural funds from private and public sources, colleges in the Midwest and elsewhere installed elaborate autotutorial classrooms and labs. At Los Angeles Valley College, a study was made of the learning outcomes from the "multiple assignment," a method of assigning four or five students to a single patient so that the instructor might be responsible for a clinical group of 16 to 20 students. Bronx Community College was funded to install closed-circuit television cameras in 15 hospital rooms, allowing the instructor to observe student's performance from a central location. Through a receiving set in the student's ear, the instructor gave feedback to the students as they were observed carrying out the clinical assignment. These examples show the variety of creative approaches undertaken to extend faculty resources during the decade of rapid expansion. Enthusiasm and vitality still characterized ADN education as the decade ended and the 1970s began.

By 1975, the number of programs had risen to 618 (ANA, 1980-1981), and the status of AD education became a heated national issue. The ANA Position Paper of 1965 had proposed differentiating credentials and work roles for graduates of ADN and BSN programs, but little progress had been made. In 1978, ANA delegates endorsed resolutions that restated the organization's position on the baccalaureate degree as minimum requirement for professional nursing practice and set deadlines for implementation. At the level of its leadership, voices in nursing expressed concern about the number and quality of associate degree and practical nurse programs and argued for actively restructuring nursing education to create an orderly two-level occupation. Associate degree educators saw threat and denigration in the escalating rhetoric, and responded self-protectively. In curriculum and teaching, practices became more conventional. As the rapid growth period leveled off, years of tenure among faculty stretched out, and curricula consolidated into stable patterns.

The decade of the 1980s was contentious. Within the circles in nursing where Entry into Practice is a topic of interest, it was a decade of arguments between partisans who, for the most part, did not understand, listen to, or care about the assumptions underlying the adversary's position. Policies and practices of the national nursing organizations appeared inimical to the interests of associate degree education. At the same time, faculty were facing new pressures on the curriculum. The advent of prospective payment financing and its sweeping impact on the acuity level of the hospital patient population prompted faculty to demand a higher level of skill performance from graduating nurses. Changes in the structure and standards of the licensing examination added to the stress. Community colleges were forced into austerity measures, and ADN faculty became increasingly separated from others in nursing education. Confined by the lack of resources and by the pressure of work at home, and not tempted to put much effort into mingling in a possibly unfriendly professional world, the separation from other educators intensified. The result has been isolation for the faculty and increasing institutionalization of the curriculum. Credit hours in ADN programs crept up, prerequisites increased, and the conviction that both were necessary to quality settled in. By 1990, the rebels had achieved the dubious distinction of being traditionalists.

If the 1950s was the decade of innovation, the '60s of expansion, the '70s of consohdation, and the '80s of isolation and institutionalization, what is the word for the '90s? Certainly status quo is not an option; continuing change in the health-care system is a certainty.

Associate degree educators have not paid much attention to the curriculum revolution. In part, this is because of the segmentation alluded to earUer: baccalaureate and graduate faculty attend one set of meetings; associate degree faculty attend fewer and different meetings. And the curriculum revolution presentation and publications have been by educators with baccalaureate and graduate school identities, at meetings attended largely by their peers. In addition, the thoughtful literature on this topic grapples with issues that seem not quite relevant to the ADN teacher's most compelling concerns. Still, as exrevolutionaries, I believe ADN educators should move themselves into the thick of it. Tanner's invitation to join in the struggle to find ways in which "the concerns of practice can truly be addressed by our educational activities, where classroom learning might be the application of practice rather than the other way around" (Tanner, 1988) is one extended to all who engage in conduct of teaching for the practice of nursing.

More than anything else, I would hope that the revolution will bring baccalaureate, graduate, and associate degree educators to a common forum for discussing educational change. There was in the first two decades of AD education an intellectual interest, even excitement, in crafting differences of both content and method among programs. Eroded by the politics of the entry issue, the loss of this shared activity has numbed our progress as an educational system. It is my earnest hope that we can once again broaden the framework within which we deliberate education issues to include the whole spectrum of education for nursing practice.

That nursing must come to accept and be comfortable with a multilevel system of education for the foreseeable future seems to me an inescapable reality. I have argued elsewhere (Waters, 1988a, 1989) and will not repeat here the demographic and economic forces that I believe will preserve the present pluralistic system despite contrary professional ideals and proposals. Working within the boundaries of politically acceptable strategies, I believe we can advance the system to satisfy the highest standards of quality, clarity, and equity. But it will require a major change in nursing education dialogues, in who talks with whom, and how the topics of common interest are framed.

From here, the 1990s appear to be a critical decade for the associate degree educational program. By the new century, significant changes in the shape and focus of the curriculum may have been accomplished. With generous support from the WK Kellogg Foundation, long a benefactor of associate degree nursing, a national campaign in the first third of the decade wiU enjoin associate degree educators to fashion curricula that value and instruct for the practice of nursing in long-term care settings as well as acute care settings (National League for Nursing, 1988, Waters, 1988b). The case for such a curriculum change obviously Ues in the implications for health-care delivery of the aging U.S. population. Similarly, the decision makers in curriculum matters are scaling down and reformulating purposes for instructional time allocated to nursing practice skills applied in the care of maternity and pediatric patients. Guided historically by the dimensions of the registered nurse role in first employment, associate degree educators are exaniining curriculum balance and emphasis in light of new graduate employment data reported by the National Council of State Boards (Kane, 1986).

Pressured by the coercion of fixed lower- division parameters and the compulsion to respond to work-world reality, the programs are at the same time accommodating a student population of ever-increasing diversity. Age, ethnicity, native language, academic background, and other learning-linked student characteristics have historically represented a wide range in community college nursing programs, but in a still sharpening trend, grow ever more diverse.

Thus, the 1990s call for experimentation and innovation once again. As in 1950, the status quo in education will not suit the coming decade. The client population, the health deUvery system, and the students who declare themselves the nurses of the future are the conscience of the curriculum revolution. As educators who care, in the profession that cares, how can we not rally to the cause?

References

  • American Nurses' Association. (1980-81). Facts about nursing. Kansas City, MO: ANA, p. 152.
  • Bevis, E.O. (1988). New directions for a new age. In Curriculum revolution: Mandate for change. New York, NY: National League for Nursing, Publication No. 15-2224, p. 44.
  • Kane, M., et al. (1986). A study of nursing practice and role delineation and job analysis of entry level performance of registered nurses. Chicago, EL: National Council of State Boards of Nursing, Inc.
  • Matheney, R. V. (1964). Application of a patient-centered curriculum in an associate degree program. In Abdelah, F. G., et al (eds.), Patient-centered approaches to nursing. New York, NY: MacMillan Company, pp. 69-96.
  • Montag, M.L. (1959). Community college education for nursing. New York, NY: McGraw-Hill Book Company, Inc., pp. 113-118, 340.
  • National League for Nursing. (1988). Associate Degree Nursing and the Nursing Home. New York, NY: NLN, Publication No. 15-2241.
  • Sherman, S. (1988). Models in associate degree nursing programs for long-term care. Strategies for long-term care. New York, NY: National League for Nursing, Publication No. 20-2231, pp. 395-407.
  • Tanner, C. (1988). Curriculum revolution: The practice mandate. Nursing and Health Care, October, 430.
  • Waters, V. (1988a). Restricting the RN license to BSN graduates could cloud nursing's future. Nursing and Health Care, March, pp. 143,146.
  • Waters, V. (1988b). The community college's role in long-term care education. In Strategies for long-term care. New York, NY: National League for Nursing, Publication No. 20-2231, pp. 389-394.
  • Waters, V. (1989), Transforming barriers in nursing education. In Curriculum revolution: Reconceptualizing nursing education. New York, NY: National League for Nursing, Publication No. 15-2280, pp. 91-99.

10.3928/0148-4834-19900901-09

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