Organized education for nurses began about a hundred and fifty years ago. For about the first hundred years, most of this education took place in hospital-based and hospital-owned schools. The apprentice like system assumed that students would exchange their labor for instruction in nursing and, beginning in the twentieth century, access to examination for registration as professional, licensed nurses. In the late 1940s, eleven hundred hospital-owned schools of nursing educated almost all the nation’s nurses. Now, there are, perhaps, a dozen or so such schools in all of the United States and none in Canada. They were replaced by schools of nursing in community colleges, comprehensive colleges, and universities.
Changes in Nursing Education and Nursing Practice
Today almost all nurses are educated in either two year or four programs in community colleges, comprehensive colleges and universities where they exchange tuition for instruction, which, among other things, leads to examination for registration as a professional nurse. More than half of all those now studying nursing are in associate degree (two-year) programs; these students are preparing to practice as generalists. Others are enrolled in baccalaureate or masters programs to earn their first nursing credentials. This background of widely different and changing educational routes to the practice of nursing makes the story of nursing education and practice much more complex. Why and how have all these changes taken place?
Background for These Changes
We can understand the recent history of nursing in the context of a rapid and continuous growth in numbers. There were about 300,000 nurses in the United States in 1940. Now there are about 3,000,000; this growth took place amid almost constant complaints about a shortage of nurses. But, we can also understand this history in the context of changes in society’s expectations of nurses. Education for professionals is intended to produce safe and competent practitioners, be they nurses, doctors, or engineers. Sixty years ago it didn’t really matter that nurses did not know anything about the electro-physiology of the heart. No one expected a nurse to re-start a stopped heart or correct an arrhythmia. Neither the knowledge nor technology existed for such interventions. If your heart stopped, or you developed an intractable arrhythmia, you died.
On the other hand, nurses were expected to prevent the spread of bacterial infections among patients in hospitals. They were expected to dispense medications as prescribed by physicians, and they were expected to keep order within the patient care units, to keep their patients safe from harm, well fed, clean, and comfortable. Most people thought the best way to learn these things was through experience and through fidelity to consistent systems of practice. Most people thought that the measure of a good nurse was that he or she exercised good judgment based on experience and following these accepted patterns of practice.
What changed over the years after 1950 was the growing expectation that the good nurse could and would be able to recognize a wide range of patient needs and be able to provide care correctly. Once we knew how to start stopped hearts, it was quite crucial that the nurse at the bedside be able to know when and how to do it. Many nurses in clinical practice—and nurse educators—discovered in the 1950s and beyond that following routine was not good enough. They began to conclude that merely using established systems and sticking to procedures was not really safe. Moreover, they realized that they would not be thought to be competent if that was all they could do.
As the public and other health care professionals began to expect that nurses would identify and solve care problems on their own, using student nurses to provide patient care began to be seen as increasingly unsatisfactory. Students could not be relied upon to recognize serious patient-care problems, let alone deal with them. So relying on student nurses to carry out established systems of care, which is what our system was willing to pay for during the first hundred years of nursing education began to be seen as not good enough. This type of education began to be judged as low quality and even dangerous. After World War II, as the expectation of how much and what kind of nursing hospital patients needed changed, people were less and less willing to put their lives in the hands of student nurses. They wanted fully educated nurses. Nurse and hospital administrators, physicians, and community leaders began to place a higher value on the fully educated, knowledge-bearing nurse giving direct care to sick people.
As what nurses were paid to do became much more complex the sites in which nurses worked also changed. For instance, intensive care units became common in hospitals in the late 1960s and early 1970s. And, as more chronically ill people were cared for at home after Medicare became law in 1965, more and more professional nurses were sought to care for the sick in their homes.
Finally, there is another point to add to this litany of change. Since 1950 our idea of who is an expert, an authority, or an elite nurse has changed. In 1950, an expert nurse was one who had risen to the top of the hospital, agency, or school hierarchy in which he or she worked. An expert was someone who, through experience, knew how to recognize and solve problems and how to administer and staff the hospital’s patient care units. A nurse’s personal authority, was, in most cases, vested in the office she or he held. And being an elite was, in most cases, associated with the status of the hospital, school, or agency where the nurse was employed.
Today, an expert nurse is one who has shown through education and demonstration of special knowledge that he or she is capable of recognizing and solving unique, individual problems and getting good results. While experience is always valuable in learning to recognize and intervene effectively in medical emergencies, authority and expertise are almost always associated with educational attainment. The track record is the usual source of proof although expert peer opinion also counts. Authority is almost always associated with educational attainment, recognition by peers, publication or public recognition. And, the elite are those who pass the tests of expertise and authority most of the time and last the longest in the game. Being an elite nurse is an individual matter, in most cases, although it doesn’t hurt to work or practice in a respected place.
The investment society is willing to make in educating nurses depends on the expectations placed on them. Nurses have been very important to society for a long time, but in the last half century people rather quickly turned to nurses to know and do more. Equally important is the change in self-expectation on the part of nurses. Nurses in the latter part of the twentieth century began, to an extent not found in previous generations, to see themselves as knowledge workers. More and more nurses came to believe that education was a good investment for them and came to expect life-long careers. The education they sought offered knowledge and expertise to recognize and solve patient care problems.
Joan E. Lynaugh is Professor Emerita of Nursing, University of Pennsylvania School of Nursing and Director Emerita of the Barbara Bates Center for the Study of the History of Nursing.