Journal of Nursing Education

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Establishing Consensus About the Baccalaureate Entry-to-Practice Policy

Ann Rhéaume, PhD

Abstract

ABSTRACT

This article is based on the results of a qualitative study examining educational reforms in New Brunswick, Canada, during the 1980s. Using the province of New Brunswick as a case study, three issues related to the baccalaureate entry-to-practice policy are examined. First, the process of upgrading nursing education to a baccalaureate degree and the conflict this change created between the Nurses Association of New Brunswick and the New Brunswick Nursing Union are described. Second, the reasons leaders of the professional nursing organization desired to upgrade nursing education are examined, and third, the issues underlying the conflict over nursing education are discussed

Abstract

ABSTRACT

This article is based on the results of a qualitative study examining educational reforms in New Brunswick, Canada, during the 1980s. Using the province of New Brunswick as a case study, three issues related to the baccalaureate entry-to-practice policy are examined. First, the process of upgrading nursing education to a baccalaureate degree and the conflict this change created between the Nurses Association of New Brunswick and the New Brunswick Nursing Union are described. Second, the reasons leaders of the professional nursing organization desired to upgrade nursing education are examined, and third, the issues underlying the conflict over nursing education are discussed

In 1982, the Canadian Nurses Association (CNA), which is the national organization representing nurses in Canada, adopted a policy proposing to abandon the non-university diploma program (a 2-year to 3-year course leading to nursing licensure as the lowest level of entrance into nursing) in favor of a 4-year baccalaureate program. The CNA policy aimed to eliminate both hospital-level and college-level nursing schools across the country. These closures would be significant, particularly because, in 1982, 85% of nursing students were enrolled in diploma programs (Statistics Canada, 1983). Although the two-tiered system of nursing education had been in place since the early 1900s, the college-based programs had consistently higher rates of enrollment than university-based programs.

Nurses in Canada are represented by both provincial and national nursing organizations. The regulating power rests with the provincial nursing organizations, while the CNA has a far-reaching mandate that promotes standards of nursing practice, education, research, and administration. The CNA initiated the baccalaureate policy and coordinated the efforts of provincial nursing associations to implement the changes in their provinces.

The adoption of the baccalaureate policy has been extremely controversial. Provincial nursing unions have opposed higher education requirements for nurses (Richardson & Sherwood, 1988). Union leaders and members, the majority of whom hold diplomas, are concerned about the future status of diploma nurses. They fear the gradual devaluation of diploma graduates and the high cost of upgrading formal nursing qualifications that may be required. The situation in the province of New Brunswick is particularly interesting because of the conflict that occurred between the New Brunswick Nursing Union (NBNU) and the Nurses Association of New Brunswick (NANB), a professional nursing organization. The NANB asked nurses to vote on the baccalaureate policy during an annual meeting in 1987, and the nurses voted against and defeated the policy. Two years later, after negotiation and compromise, the NANB asked nurses to vote again on the education policy, and they accepted it.

The move to upgrade nursing education is not unique to Canada. In 1965, the American Nurses Association passed a resolution to make baccalaureate education a requirement for entry into nursing practice by 1985, but the proposed policy created opposition, and the deadline was extended to 1995. Several nursing groups expressed concern regarding the costs of the policy, the legal processes involved in its implementation, the devaluation of current students in diploma programs, the policy's marketability, and some issues relating to the curricular changes it would bring (Stevens, 1985; Warner, Ross, & Clark, 1988; Waters, 1986).

Currently, North Dakota is the only U.S. state that requires the baccalaureate degree for entry into practice (Lusk, Russell, Rodgers, & Wilson-Barnett, 2001). Australia successfully upgraded nursing credentials in 1992, while the United Kingdom is moving toward major reforms in nursing education (Marquis, Lillibridge, & Madison, 1993; United Kingdom Central Council, 1986).

Many articles in the nursing literature discuss the baccalaureate entry-to-practice policy, exploring the beliefs of nursing leaders, including arguments related to the justification of upgrading nursing education (Jacobs, DiMattio, Bishop, & Fields, 1998) and descriptions of nursing education changes in various countries (Barter & Leniban McFarland, 2001; Lusk et al., 2001). One exception is Warner et al.'s (1988) content analysis of the entryto-practice arguments presented in North Dakota's testimonies during the 1980s.

THEORETICAL PERSPECTIVES

This study used three theoretical frameworks - interactionist, social closure, and feminist - to examine the changes in nursing education. The interactionist approach to the study of occupations and professions focuses on how members within occupational groups view their social world and construct their careers (Hughes, 1965, 1971), exploring division of labor and the ongoing negotiation and conflict over work mandates. Factions within an occupation may be in conflict over issues such as the nature of work, the relationship with allied occupations (e.g., shifting work boundaries) and long-term occupational goals (Bücher & Strauss, 1961). Applied to nursing, the interactionist approach suggests that the conflict over the entryto-practice policy within nursing may be due to different goals and visions of factions within nursing.

Neo-Weberian closure theory addresses the collective action undertaken by occupational groups to advance their opportunities within the labor market (Parkin, 1979). This approach underlines the importance of the state in influencing occupational outcomes. Social closure includes exclusionary strategies, such as the use of credentials to close off opportunities to subordinate groups. Usurpationary closure refers to the use of power by groups to claim resources from more privileged groups and is the counterpart of exclusionary power. Usurpationary strategies, such as strikes and demonstrations, are a response to exclusion. During different periods, both British and American nurses have used exclusionary strategies to limit access to resources or increase opportunities within the labor market (Chua & Clegg, 1990; Powell, 1987; Witz, 1992). For example, during the late 1800s in England, nurse exclusionary strategies were class and gender based (i.e., the leaders of nursing wanted women from upper-class backgrounds to become nurses). However, the upper-class exclusivity became hard to maintain during periods of war, and knowledge became a new exclusionary rule used to define professionalism. Closure theory, when applied to nursing, suggests that the entry-to-practice policy was a strategy used by nursing to increase its advantages within health care.

Feminist writers have criticized previous work within the study of occupations and professions for their androcentric biases (Crompton, 1987; Davies, 1995; Witz, 1990, 1992). Feminist writers posit that nursing's subordinate position within the health care system is partially due to women's position within society (Carpenter, 1993; Garmanikow, 1978). Witz (1992) further elaborated neoWeberian closure theory and argued that gender makes a difference in the form and outcomes of professional goals. Female-based occupations, more than male-based occupations, may create a clear division of labor between themselves and lesser skilled health care workers. In relation to nursing, feminist perspectives suggest that the upgrading of nursing education is an attempt to change nursing's subordinate status in a male-dominated health care system.

METHOD

This study sought to answer the following questions:

* Why did nursing leaders seek to upgrade nursing education?

* What happened when nursing leaders attempted to implement the nursing education policy in New Brunswick?

* What positions were taken by different groups within and outside of nursing?

* Why were these positions taken?

This article is based on archival material from nursing organizations and interviews with key people involved with the new baccalaureate entry-to-practice policy at the provincial level in New Brunswick and at the national level during the 1980s. Archival material from three nursing organizations, the CNA, NANB, and NBNU, consisted of minutes from meetings, internal reports, speeches from organization leaders, correspondence letters, internal memos, and notes from between the years 1978 and 1990.

The archival research was supplemented with 19 indepth interviews with nursing leaders from the CNA, NANB, and NBNU; government officials; and other key people involved with the new entry-to-practice policy. Interviewees were identified through the archival material, professional nursing literature, and other respondents' suggestions, and were initially reached by telephone. The purpose of the study was explained to them, and they were asked for their consent to be interviewed. The majority of the interviews (10 of the 19) were conducted in person at the respondents' workplaces. Travel distances did not permit all of the interviews to be conducted in person. Interviews lasted between 1 and 2V6 hours. Notes taken during the interviews were transcribed immediately. The interviews were not recorded because it was feared that respondents would be reticent to freely express their views, and several respondents did, in fact, express relief that no opinions were recorded.

The archival material from each committee within an organization was placed in chronological order. The material was reviewed to determine the order of events, the nature of decisions and the rationale behind them, and the key decision-making individuals. Afterward, the material from each committee within an organization was merged to show how the committees interacted with each other and which committees had more decision-making power. Lastly, the material from each organization (CNA, NANB, and NBNU) was placed in chronological order.

The interview data was summarized using content analysis to identify common themes related to the baccalaureate entry-to-practice policy. The data was initially grouped into 21 broad themes, which were then further grouped into subthemes. Then, summarized data from the archival material was integrated into the results of the content analysis from the interviews.

OVERVIEW OF CONFLICT OVER NURSING EDUCATION

The conflict over nursing education in New Brunswick occurred among a number of groups (Rhéaume, 1998). Policy supporters included CNA and NANB leaders, university nursing teachers, and many baccalaureate prepared nurses. Union leaders, diploma teachers, and many diploma nurses were opposed to the new entry-to-practice policy. Diploma graduates feared the devaluation of their credentials and were concerned with access to upward job mobility. Union leaders argued they were not against higher education for nurses but believed graduates of diploma programs still had an important role to play in health care. Although they agreed with the baccalaureate entry-to-practice policy, the diploma teachers representing diploma programs expressed concern related to the loss of their jobs, the methods used by nursing leaders in pursuing the new policy, and the planned closure of schools in which they had taught and nurtured nursing students.

There were 6,879 RNs in New Brunswick in 1987, the year the NANB asked nurses to vote on the baccalaureate degree as a requirement for entry to practice (Statistics Canada, 1987). All nurses are required to belong to the NANB in order to practice. Of these 6,879 RNs, the NBNU represented 5,695 union members, the majority of whom were staff nurses working in hospitals (Hoyt-McGee, 1994). All nursing staff are eligible for union membership and must become members upon employment. However, the percentage of inclusion decreases as nurses hold higher organizational positions (Rhéaume, 1998). The elite members of the nursing community are not members of the union. They are more educated and hold more powerful positions within health care. Key positions within the nursing union are generally held by staff nurses, some of whom do not have baccalaureate degrees.

The NANB established a committee to study nursing education shortly after the CNA adopted the baccalaureate entry-to-practice policy in 1982. The committee, consisting of nurse educators and nurse managers, had no representation from bedside nurses. At the end of 4 years of study, the NANB committee decided to support the baccalaureate education policy and asked for a membership vote on the policy in 1987. Data from the study identified three obstacles that could stop the NANB from implementing educational reforms, and the NANB systematically and successfully overcame each obstacle.

The first obstacle was the lack of a legal mandate to fully control and, therefore, change nursing education standards. The Nursing Act of 1957 gave the NANB the right to approve schools of nursing and to prescribe the student experience and general syllabi of the schools (New Brunswick Association of Registered Nurses, 1957), but otherwise, its powers related to nursing education were limited. The NANB lobbied for a new nursing act that would give it the exclusive responsibility to develop, establish, maintain, and administer standards related to education and practice, and the Nursing Act of 1984 gave the NANB the right to set minimum education requirements for nurses (NANB, 1984).

The second obstacle was the need for the provincial government's approval of any proposed changes in nursing education. Although the NANB had the legal mandate to change nursing education standards, education and health care are generally publicly funded, so the provincial government would need to support any change that increased its financial commitment. The provincial government waited until 1991 to support the new entry-topractice policy. Several CNA and NANB leaders stated that the provincial government supported baccalaureate education because of its overall belief in the value of education, but data from the author's current study suggests two other factors influenced the government's decision: the five diploma schools in the province were very costly to operate, and the government wished to decrease the funds allocated to them; and the educational reform fit into the provincial government's overall plans to reduce health care expenditures.

This obstacle was overcome by permitting the NANB to upgrade nursing qualifications. In return, the provincial government decreased the ratio of nurses in the health care system and increased the number of auxiliary staff (i.e., nursing assistants).

The third obstacle was the nurses themselves. A majority of nurses in New Brunswick would have to accept the credential change. The following paragraphs describe the sequence of events related to this last obstacle, reconstructed from both interviews and archival data.

The NBNLFs convictions regarding the role of diploma nurses led it to defend their place within the health care system. The NANB had a grandfathering clause that protected diploma nurses' right to practice. However, the clause did not encourage upward mobility, and baccalaureate nurses would be eligible for many nursing positions for which diploma nurses would not be eligible. The NBNU hoped for experience as well as education to be essential for mobility and developed an amendment to the entry-to-practice resolution 2 months before the NANB planned to bring the policy to a vote. The amendment stated that diploma nurses' right to practice would be guaranteed and their past experience would be considered for mobility and promotion to other positions within nursing, such as head nurse. NANB leaders believed nursing standards in education and practice would be compromised if experience were used as a criterion alongside education for advanced positions in nursing. The NANB did not accept the union amendments.

The NBNU5S opposition to the baccalaureate entry-topractice policy in 1987 was pivotal during the annual NANB meeting, in which the NANB asked nurses to vote on the proposed policy. Prior to this meeting, both the NANB and NBNU toured the province, lobbying the nurses for their support. The discussions in the NANB meetings focused on the greater responsibilities nurses would have in the future health care system and the preparation needed for these more complex roles.

As the 1987 vote neared, the NBNU also organized local meetings with its members across New Brunswick. However, the union meetings attracted a very différent authence than the NANB meetings. The NBNU meetings often attracted staff nurses from hospitals, many of them diploma graduates, while the NANB meetings generally attracted nurses with baccalaureate degrees who wished to become more involved with the NANB. The discussions in the union meetings revolved around issues of great concern to diploma nurses: the value of work experience, remuneration, and accessibility of university education for practicing nurses with diploma degrees.

The NANB asked nurses to vote on the baccalaureate policy during an annual meeting in 1987. Forty-one percent of the NANB membership voted. The baccalaureate entry-to-practice resolution was defeated by a margin of 2.4%. Policy supporters blamed the initial rejection on the negative campaign mounted by the NBNU in opposition to the change and claimed the union was involved in buying "no" votes. Three months after the vote, the NANB investigated the allegations and annulled the vote on the grounds of vote interference and intimidation.

Two years later, in 1989, the NANB asked nurses to vote on an amended policy. The NANB conceded to the NBNU demands for protection of diploma nurses. The union supported the baccalaureate entry-to-practice policy during the 1989 membership vote, and the policy passed without disruption.

REASONS NURSING LEADERS SUPPORTED THE NEW POLICY

There are several reasons nursing leaders supported the baccalaureate degree in nursing as a requirement for entry to practice. Publicly, professional nursing organizations stated that university education is necessary to prepare nurses for working in an increasingly complex work environment (Rhéaume, 1998).

Data from this study suggest two additional reasons:

* Nursing leaders want nursing to be perceived as a profession and believe university education will facilitate this goal.

* Nursing leaders maintain that upgrading nursing education will enable them to expand nursing tasks and, in doing so, address the problem that an increasing number of traditional, valued nursing tasks are being performed by other health care occupations.

To Increase Nurses' Knowledge to Work in a Complex Health Care System

Leaders of the professional nursing organizations stated that university education is necessary to prepare nurses for ongoing changes in the health care system and that the baccalaureate degree will enable nurses to provide the best patient care possible (Rhéaume, 1998). Underlying this argument are the assumptions that nursing practice is becoming more complex and that diploma education does not equip nurses with the knowledge or skills needed to work in a changing health care system. Respondents from the CNA and NANB spoke of the numerous differences between diploma and baccalaureate nurses. They believed baccalaureate nurses are superior because they have greater depth of knowledge and are better communicators, problem solvers, and leaders. Leaders of the professional nursing associations conceded that diploma nurses do have some advantages over baccalaureate nurses, such as better technical and physical assessment skills, but these skills are not valued as highly and do not justify the continuation of the two-tiered system. In addition, these respondents argued that baccalaureate prepared nurses will gain these skills with work-related experience. Nursing leaders conceded that there was little empirical evidence to support their assertions at the time of their decision to support the entry-to-practice policy.

However, there was dissension among the nursing leaders regarding nurses' role within health care (Rhéaume, 1998). There was also disagreement among respondents about what kind of knowledge and skills are required for nursing practice. The respondents had two distinct views of nursing practice.

In the first view, nurses are defined in terms of bedside patient care. Nurses are predominantly caregivers, and hands-on care is the essence of nursing. Activities such as bathing patients allow nurses to respond to subtle, yet important, cues related to patient needs. All nurse-related tasks become meaningful and have broader significance, which may positively affect patient outcomes.

In the second view, tasks nurses perform are less routine and more specialized. Nurses oversee other health care workers providing bedside care, intervening when particular situations warrant expert skills. Thus, nurses become patient coordinators with specialized skills.

These views are not mutually exclusive. Some respondents saw nurses moving in and out of the coordinator role as situations change and patient needs arise. These respondents, the majority being from the professional nursing associations, believed nurses should have the autonomy and flexibility to change practice components.

There was broad agreement that theoretical knowledge gleaned from a number of disciplines, including the pure sciences, social sciences, and nursing itself, was relevant for practice. The respondents listed and discussed four broad categories of skills: communication, psychomotor skills, critical thinking, and assessment. A majority of respondents from the professional nursing organizations and university teachers believed communication and critical thinking skills were important, while a majority of union leaders and diploma school teachers described the necessity of good psychomotor and assessment skills. A smaller number of CNA and NANB leaders stated that nurses should have good teaching, managerial, and professional skills.

To summarize, respondents did not share the same vision of what constitutes nursing practice, nor the education that is required for this practice. CNA and NANB leaders generally supported the view that nurses are members of a knowledge-based profession, who coordinate patient care and intervene in complex patient situations. The leaders also believed a different set of skills is required for this (e.g., theoretical knowledge, communication skills). Union leaders and diploma teachers, on the other hand, tended to support the vision of nurses who possess more practical skills, which they consider important for bedside nursing care.

To Be Viewed as Professionals

The majority of respondents acknowledged that nursing is seeking widespread recognition as a profession (Rhéaume, 1998). Underlying the decision to upgrade nursing education is the belief that a baccalaureate degree will allow nursing to achieve professional status (CNA, 1981; Cyr, 1987; Rodger, 1984a, 1984b, 1984c). Several respondents considered long periods of education a parameter that sets professional groups apart from other occupational groups. For CNA and NANB respondents, there was a clear demarcation between professionals and other groups, such as technicians. Diploma nurses are viewed as technicians, which is linked to unionism, and have lower status than baccalaureate nurses. CNA and NANB leaders were fundamentally opposed to unions because they believed unions are incongruent with being members of a profession. Unionism is associated with blue-collar workers and does not fit the professional image they desire. There was a belief among these respondents that university education would make nurses less union dependent.

Although many respondents from the CNA and NANB referred to the advantages of being considered members of a profession, they had difficulty articulating or defining these advantages. Some respondents described the advantages in terms of greater decision making or political power within the health care system. For example, a leader from the NANB stated that a baccalaureate degree would enable nurses to obtain more power in hospitals. Having a complete, university-educated workforce has the potential to reverse nursing's traditional subordination to both hospital administrations and medicine. Other respondents indicated that a more highly educated workforce would increase salaries. Lastly, CNA and NANB leaders believed a university education and the status accorded to it would improve nursing's image, which would help to solve some of the recruitment problems in nursing and attract more intelligent women to the occupation (CNA, 1981).

To Expand Nursing Roles

The majority of respondents were concerned about their working relationships with ancillary health care workers. For many nursing leaders, regardless of their organizational affiliation, there was a growing sense that core nursing tasks are shrinking as other health care workers claim expertise in areas of patient care that were once part of nursing. Examples were provided of physiotherapists and respiratory therapists who took on valued nursing tasks. A statement from a past NANB's presidential address during the 1987 annual meeting portrays this fear:

Nurses must look forward and be willing to upgrade their standards, especially at a time when other professionals are chipping away at areas of our professional practice base. Our survival is dependent on our ability to adapt to change. Having an educational base on par with that of other professionals will show that we are prepared to meet that challenge. (Cyr, 1987, p. 12)

Nursing leaders from the CNA and NANB believed upgrading nursing education to a baccalaureate degree is one way to respond to this threat and enable nurses to expand their own roles. For example, nurses can coordinate other health care workers to deliver patient care. Multidisciplinary teams are commonly used in hospitals in an attempt to decrease fragmentation of patient care when several health care workers are involved. Although nurses generally are members of the multidisciplinary team, respondents indicated that nurses should play a greater role in managing the team. Nurses, because of their holistic vision, are able to unite these multiple perspectives and prevent fragmentation of patient care.

Respondents stated that nurses must have an egalitarian, collaborative relationship with other health care workers to fulfill this role. They believed nurses' credibüity with other health care workers would increase if nurses had university educations. Nursing leaders were very concerned that nurses are often the least educated group of workers directly involved with patient care and believed this places nurses at a disadvantage.

DISCUSSION

This study supports the use of multiple theoretical perspectives in studying issues as complex as changing entrance requirements. The interactionist perspective assumes there is internal dissidence within occupations, as factions within those occupations disagree over work mandates and long-term goals. Data from this study supports this perspective. Several factors were at the root of the conflict within nursing. The union supported a two-tiered system of nursing education because union leaders, unlike NANB leaders, believed a large part of nursing practice should remain at the bedside. This view did not preclude nurses from having expanded roles. However, union leaders believed diploma nurses were able to provide the care needed to sick patients in a changing health care system. In addition, union leaders had a mandate to protect the majority of its members, who were diploma nurses. On the other hand, leaders of the professional nursing organizations supported the baccalaureate entry-to-practice policy because they believed nurses needed the education for their practice and that it would enhance their status and help expand their roles within health care.

The difference in opinions between leaders may be partially related to the difference in leadership profiles. Although there is substantial overlapping membership between the two organizations, the leaders of the professional nursing organizations typically are not members of the union. They are generally more educated and are nurse administrators or educators, whereas union leaders generally are staff nurses or head nurses, who sometimes do not have university degrees. This disparity of background education and work experience among nursing leaders may contribute to ongoing tension between the two organizations and reflect different approaches to issues and visions of nursing practice.

Second, the NANB and the NBNU have particular visions of their mandates that do not correspond to each other's perceptions. The NANB felt the union did not have a mandate to contribute to setting educational standards. While this is true, union leaders believed their organization should play a significant role in the development of the nursing education policy. In addition, union leaders argued they had the right to suggest their members vote a certain way to protect their interests.

The baccalaureate entry-to-practice policy reignited a conflict between the NANB and the NBNU. In Canada, the professional nursing organizations were responsible for collective bargaining prior to 1973. However, a Supreme Court decision separated collective bargaining from the functions of a professional organization (Jensen, 1984). The differentiation of tasks in New Brunswick occurred in 1978, with the establishment of the NBNU. Prior to this, the NANB was the sole voice speaking on behalf of nurses and was responsible for setting practice standards, the discipline of members, and collective bargaining. The NANB continued to act as if it were responsible for all facets of nursing. These attitudes have, at times, led the NANB to ignore the NBNU as an organization that may provide valuable input into nursing's future, such as with the entry-to-practice policy. On the other hand, the NBNU also believed it had a significant role to play in mapping out nursing's future.

Closure theory focuses on strategies, such as exclusion, used by dominant groups to maintain or enhance its position (Parkin, 1979). Findings from this study support the use of this perspective. The entry-to-practice policy was instigated by national and provincial nursing leaders, who are among the most educated nurses, holding the most powerful administrative and educator positions in Canada. The policy may be interpreted as an exclusionary strategy because it closes off opportunities to women who would typically enroll in diploma nursing programs. Nursing and union leaders also clashed idealistically. Nursing leaders did not believe diploma nurses could help them attain higher status and viewed them as technicians, highly dependent on union activities. Unionism is incongruent with professionalism and prevents nursing from being viewed as a profession by both other health care workers and the public.

The NBNU's response to the initial vote on the entryto-practice policy can be viewed as an usurpationary strategy. The NBNU was successful in mobilizing nurses for two primary reasons. Although working nurses belong to both organizations, they believe the union best represents their concerns and is a viable way of improving wages and working conditions (DPA, 1985). Nurses see visible gains after contract negotiations and, if new contracts are unsatisfactory, unions can easily shift the blame for contract outcomes to provincial governments. However, the NANB's objectives are less clear to nurses. Many NANB leaders are nursing administrators, which makes it more difficult for working nurses to believe this group truly represents them (Jensen, 1984).

The second reason for the union's successful mobilization of nurses was the support it had from the diploma teachers who were faced with losing their jobs. Diploma teachers in provinces other than New Brunswick were not as threatened because some provincial nursing organizations accepted articulation programs between diploma schools and universities. In this type of program, student nurses begin their degree in a diploma school and transfer to a university to complete their degree. In New Brunswick, the NANB did not desire this type of program, nor did the CNA support articulation between diploma and university programs. The diploma schools closed their doors in 1996, and many diploma teachers lost thenjobs as a result.

A feminist perspective would suggest that nursing leaders were attempting to change nursing's subordinate status in a male-dominated health care system by upgrading nursing education (Rispel & Schneider, 1991; Witz, 1992). By increasing educational requirements, nursing is effectively emulating male-dominated professions, such as medicine. Data from this study does not entirely support this view. In this study, physicians were not significant players in the education reform. Nursing leaders were not overly concerned with their views, claiming that physicians had no jurisdiction over nursing affairs. This lack of concern may be primarily because physicians were not threatening to take on valued nursing tasks. In addition, the occupations that threaten nursing are generally female based (e.g., physiotherapists, nursing assistants).

CONCLUSION

Education has always been an issue of contention in nursing. The issues outlined in this article demonstrate the complexity of problems when nursing leaders decide on new policies and their views are not shared among the general membership. This study has several implications. Conflict over issues, such as education, may be unavoidable in an occupational group as large as nursing. However, internal conflict over issues should be viewed less negatively and more as a naturally occurring process. Second, although professional nursing organizations and nursing unions have different mandates, both groups have functions that benefit nurses. Nursing leaders, regardless of their organizational affiliation, should strive to understand the other group's point of view and attempt to resolve conflictual issues before they become problems. For example, cooperation between organizations such as the NANB and NBNU through the use of committees with shared membership should be encouraged. NANB and NBNU leaders both recognized that it took several years to rebuild relationships between the two groups and have made efforts to include representatives from each organization in key decision-making committees. The conflict over the baccalaureate entry-to-practice policy left many nurses disillusioned with their leaders' performance, and it took a number of years for each organization to regain the trust of its members.

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