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History Lesson: Nursing Education Has Evolved Over the Decades

Nurse comforting patient sitting on couch

The 1893 World's fair in Chicago introduced Americans to hamburgers, the Ferris wheel, the Pledge of Allegiance — and the idea of higher education for nurses.

That exposition hosted "the first really global meeting of nurses," said nurse historian Louise C. Selanders, RN, EdD, FAAN, professor of nursing at Michigan State University and co-author of "Florence Nightingale in Absentia: Nursing and the 1893 Columbian Exposition," published in the Journal of Holistic Nursing in 2010. Nurse leaders of the time — including Nightingale, who did not attend the conference but had her last significant paper presented there — argued for an educated workforce with standards of practice, as opposed to one in which nurses served as apprentices in hospitals, which was customary at the time, Selanders said. 

From that World?s fair meeting through the 2010 Institute of Medicine report, "The Future of Nursing: Leading Change, Advancing Health," which calls for increasing the number of baccalaureate-prepared nurses to 80% and doubling the number of nurses with doctoral degrees by 2020, nurse leaders and educators have pushed for a highly educated and trained nursing workforce. Reports on nursing throughout the past 120 years have recommended higher education and greater responsibilities for nurses, but progress often was impeded by gender and class barriers, and by short-term economic demands of the healthcare industry, nursing historians said.

"Nursing education developed very haphazardly," said Julie Fairman, RN, PhD, FAAN, a Nightingale professor of nursing, director of the Barbara Bates Center for the Study of the History of Nursing and a Robert Wood Johnson Foundation investigator in health policy research at the University of Pennsylvania in Philadelphia.

Most American nurses received on-the-job training in hospital diploma schools. Nursing students were unpaid, giving hospitals a source of free labor. This created what many nurse historians and policy analysts see as a system that continues to undervalue nursing?s contribution to acute care.

"Students worked 12-hour shifts with little or no clinical supervision," wrote nurse historian Karen J. Egenes, RN, EdD, associate professor of nursing at Loyola University in Chicago, in a chapter on nursing?s history in the book "Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow," published by Jones and Bartlett. "Classes were irregularly scheduled and were often canceled when students were needed to staff the wards."

Despite reports throughout the first half of the 1900s recommending schools of nursing be moved to universities, hospitals resisted until the 1950s, when advances in science and technology transformed healthcare, Fairman said. Suddenly hospital nurses went from supporting people after simple surgeries and providing comfort care for those with "incurable" conditions, to caring for patients receiving very complex treatments, she said.

Hospitals moved their schools to universities, but the four-year baccalaureate programs could not produce nurses fast enough to meet a huge shortage. In the early 1950s, nurse educator and founder and director of the Adelphi College School of Nursing in Garden City, N.Y., Mildred Montag, RN, proposed and created a two-year associate degree of nursing program to provide technically skilled nurses to meet the immediate demand until enough baccalaureate degree nurses could be trained. The ADN programs "were meant to meet the immediate nursing shortage and then go away," Selanders said. Instead, they remained and there were three ways to become an RN: through a two-year associate degree, a three-year diploma program or four-year baccalaureate program. The BSN was the most time-consuming for students to earn and the most expensive for employers to hire. 

"That report was never implemented in the way Mildred Montag meant it to be," said Geraldine "Polly" Bednash, RN, PhD, FAAN, executive director of the American Association of Colleges of Nursing. The ADN program became popular with both nursing students and hospitals, but created confusion and "unfortunate tensions around the capacity of clinicians to provide care," she said. The American Nurses Association, trying to promote educational standards it believed would best serve patients, in 1964 declared nurses should be educated only in four-year programs.

The pronouncement "was taken very personally by nurses," Selanders said. Those who had baccalaureate degrees generally agreed with the ANA. Those with ADNs or diplomas felt let down by their professional organization and denigrated as being less than a good nurse, she said. 

The federal Nurse Training Act of 1964 pumped enormous funding into collegiate nursing education, spurring development of baccalaureate, advanced practice and PhD programs, Fairman said, but serious movement of nursing students into universities didn?t happen until the 1980s. That?s when the Institute of Medicine issued a 1983 report calling for creation of a national center for nursing research (The National Institute of Nursing Research, part of the National Institutes of Health, opened in 1985) and recommending more nurses be educated at the graduate level, Bednash said. Advanced practice nursing and nursing research "wouldn?t have happened without that report," she said.

The IOM?s 2010 report used extensive data and research to back its recommendations for nurses, including a call for a seamless academic progression to higher education, and full partnership with physicians and others in redesigning healthcare in the U.S. Nurse historians and educators said they are hopeful it will stimulate changes more so than previous reports. 

For the first time, universities and community colleges are working as partners to get nurses into four-year or higher degree programs that emphasize critical thinking, leadership, systems analysis and teamwork, while working to include students with limited resources who cannot afford traditional four-year programs, said Beverly Malone, RN, PhD, FAAN, CEO of the National League for Nursing. "Everyone is in agreement that we need the best-educated, prepared, diverse nursing workforce possible," Malone said. "There will be multiple pathways to get there, but that?s where we?re going to end up."

The report is important not only because it advocates higher levels of education for nurses, she said, but also because it calls for an end to barriers to using that advanced education, such as state regulations restricting nurse practitioners from prescribing medications without physician approval. "There?s something about the legitimacy of the IOM report" and the Robert Wood Johnson Foundation-led campaign to implement its recommendations, Malone said. "Foundations have bought into it; they are willing to give grants to make it happen." 

At the same time, she added, the IOM report wouldn?t have happened without the previous reports and recommendations for nursing education. "At their time, each one was hugely important. Each one built on the others. [The IOM report] is the right thing at the right time, just like each of those reports was the right thing at the right time."

Bednash taught in a diploma program in the 1960s. "We were supposed to stand up when the physician came on the unit," she recalls. Nurses have progressed significantly since those days, she said, but they need to remember their past as they look forward to exciting and challenging new roles — as care coordinators, primary care providers and health policymakers. "We need to keep our basic values about what nursing is. We are a profession that is caring, provides care based on science and works in partnership with others and the patient to meet health goals." •