Nursing Inquiry 2015; 22(3): 231–239
Feature
Educational silos in nursing education: a critical review of practical nurse education in Canada Diane L Butchera and Karen A MacKinnonb aUniversity of Victoria, Victoria, BC, Canada, bSchool of Nursing, University of Victoria, Victoria, BC, Canada Accepted for publication 7 November 2014 DOI: 10.1111/nin.12090
BUTCHER DL and MACKINNON KA. Nursing Inquiry 2015; 22: 231–239 Educational silos in nursing education: a critical review of practical nurse education in Canada Changes to practical nurse education (with expanded scopes of practice) align with the increasing need for nurses and assistive personnel in global acute care contexts. A case in point is this critical exploration of Canadian practical nursing literature, undertaken to reveal predominating discourses and relationships to nursing disciplinary knowledge. The objectives of this poststructural critical review were to identify dominant discourses in practical nurse education literature and to analyze these discourses to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Predominant themes in the discourses surrounding practical nurse education included conversations about the nurse shortage, expanded roles, collaboration, evidence-based practice, role confusion, cost/efficiency, the history of practical nurse education and employer interests. The complex relationships between practical nursing and the disciplinary landscape of nursing are revealed in the analysis of discourses related to the purpose(s) of practical nurse education, curricula/ educational programming, relationships between RN and PN education and the role of nursing knowledge. Power dynamics related to employer needs and interests, as well as educational silos and the nature of women’s work, are also revealed within the intersection of various discourses. Key words: critical theory, discourse, education, nursing, history of nursing, power, practical nursing.
The first author’s experiences teaching in a practical nurse (PN) program while concurrently enrolled in graduate school raised concerns surrounding relationships between nursing knowledge and practical nursing education. In addition, the recent introduction of new staffing models in hospitals in our provincial context is aligning with rapid expansion and changes to PN education and practice, including expanded roles within acute care hospital settings. Having experienced these changes through work in teaching PN students, questions emerged that were the impetus for the first author’s graduate school project – a critical analysis of practical nurse education in Canada (Butcher 2013). The purpose of this current discussion is to present a case study to review Correspondence: Diane L. Butcher, PhD Student, University of Victoria, Victoria, BC, Canada. E-mail: © 2014 John Wiley & Sons Ltd
and critically analyze discourses in Canadian practical nurse education literature to uncover underlying beliefs and assumptions, tensions and ambiguities, sources of knowledge and constructed truths. It is through this ‘interpretive vehicle’ (Thorne 2012, 281) of analysis of our case that we can add to accumulating knowledge related to global discussions of the need for nurses and assistive personnel in health-care.
HISTORICAL BACKGROUND From the expansion of North American British Colonies in the 1800s to the current context of nursing in Canada, the term ‘nurse’ has continued to refer to a ‘range of practitioners with a range of training and experience’ (Scaia and McPherson 2010, 195). Many early 19th century Catholic nuns held significant expertise as nurses and nurse
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administrators and often apprenticed under Europeantrained physicians. Lay nurses and midwives with less formal education were available for hire to provide care for middleand upper-class families and ‘sought to distinguish themselves from domestic servants, nannies or even governesses’ (Scaia and McPherson 2010, 195). While caregivers in hospitals were often aligned with the servant class, the growth of hospitals in the latter half of the 19th century created a demand for more nurses with greater skills. The expansion of hospitals, as well as discourses of physicians as medical experts, resulted in hospitals that were organized to suit medical practice (Martin Saarinen 2008). While needing skilled nurses, costs were a concern, as hospitals relied on significant financial support from the government and charitable funding. Administrators, ‘in keeping with the ideology of the born nurse, were reluctant to pay a fair wage for work that was considered an extension of domestic services’ (Martin Saarinen 2008, 19). In England, Florence Nightingale also believed that nurses performed duties that came naturally to all women. Nightingale encouraged women from upper classes of society to train for nursing management positions, while women from lower classes of society were to provide direct patient care under supervision. Thus, a hierarchy was beginning to emerge within the nursing landscape (Martin Saarinen 2008; Scaia and McPherson 2010). The Great Depression early in the 20th century (1929– 1933) created difficulties for many nurses to find employment. However, large numbers of nurses enlisted and served with the Canadian Armed Forces during World War II (1939–1945). As a result, concerns were raised about pending shortages of Canadian nurses, so the government increased funding to support enrollments in university and hospital-based nursing programs (Martin Saarinen 2008). Shorter educational programs to prepare nursing assistants were originally designed as a temporary measure to offset nursing shortages during the war. Martin Saarinen (2008) notes how governments planned to disband the programs once registered nurses returned to their civilian duties. However, RN shortages persisted after the war (partly due to the baby boom), and these shorter programs continued. Martin Saarinen (2008) observed that economics contributed to the continued employment of nursing assistants such as nurses aides and later practical nurses. Practical nurses (PNs) also graduated faster, entered the workforce more quickly and were paid a lower wage than the RN. Thus, throughout Canada, practical nurses continued to work where there were shortages of RNs (such as in residential care facilities), while RNs predominated in acute care 232
hospitals. However, persisting shortages of RNs over recent decades (created in part by the closure of RN diploma programs in support of the baccalaureate degree as entry to practice) have contributed to shifts in expectations for practical nurses. Many PN diploma programs have recently been revised (from one- to two-year programs) to prepare practical nurses for expanded scopes of practice and for working in acute care settings alongside RNs. As practical nurses are registered by Colleges of Nursing in most Canadian provinces, the designation registered nurse now has a more ambiguous meaning. In Canada today, there are three regulated groups of nurses – registered nurses (RNs), licensed or registered practical nurses (LPNs or RPNs) and registered psychiatric nurses (also RPNs). In most provinces and territories, the title LPN (licensed practical nurse) is protected. However, in Ontario, the term ‘RPN’ (registered practical nurse) is used. To avoid confusion, we will use the term ‘PN’ (practical nurse) or PN education to refer to both licensed and registered practical nurses. Registered psychiatric nurses are found primarily in Western Canada. As this review focuses on practical nurse (PN) education, we have not explored documents about registered psychiatric nurses. Significant global workforce shortages have also created the need for both regulated and unregulated assistive nursing personnel beyond Canada (American Association of Colleges of Nursing 2014). In the UK, registered nurses include first-level nurses (RNs) and second-level nurses (enrolled nurses). Enrolled/diploma nurse training is no longer provided in the UK; however, ENs can still be licensed to work as nurses (Nursing and Midwifery Council 2004). As in Canada, unregulated healthcare aides also provide nursing care. In the United States, LPNs (also known as licensed vocational nurses) are registered, in addition to RNs who are prepared through diploma, associate degree or baccalaureate degree programs (American Association of Colleges of Nursing 2014). In Australia, vocational or diploma nurses are referred to as enrolled nurses and RNs receive a baccalaureate degree for practice (Australian Institute of Health and Welfare 2013). Throughout the world, numerous titles are also utilized for unregulated personnel (such as healthcare aides, nursing assistants, nurse auxiliary) who also provide nursing care (Canadian Nurses Association 2005). The complexity of the nursing landscape raises important questions about practical or vocational nursing knowledge. How is practical nursing knowledge related to the larger discipline of nursing? Is this relationship made explicit? If practical nursing education draws on nursing disciplinary knowledge, should/does nursing literature inform practical nurse curricula, educators and practice? © 2014 John Wiley & Sons Ltd
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METHODOLOGY
Literature search strategy
A preliminary review of Canadian regulatory documents for both registered nurses and practical nurses (Table 1) provided the foundation for further analysis. This critical review of provincial and territorial regulatory Web sites of both registered nurses (RNs) and practical nurses (LPNs and RPNs) helped to elucidate whether relationships between registered and practical nursing knowledge were made explicit in various regulatory documents. Iteratively, a broader literature review was then performed to review the larger discursive landscape. The objectives of this poststructural critical review were to do the following:
To identify and analyze the predominating discourses, a dialectical and iterative approach was undertaken. Searching the library databases (CINAHL and Google Scholar) revealed 59 articles. Utilizing search terms ‘practical nurs*,’ ‘canad*,’ ‘education’ and ‘scholarly’ in the CINAHL database yielded 37 articles. Substituting ‘vocational’ for the term ‘practical’ in the original search yielded two repeat articles from the original search. Searching CINAHL with terms ‘practical nurs*,’ ‘canad*’ and ‘curricu*’ produced one article. Searching the Google Scholar database using terms ‘licensed practical nurse education’ and Canada produced 23 articles. Adding the search term ‘curriculum’ produced 14 articles from the Google Scholar database. Removing duplicates from the two Google Scholar searches resulted in 21 articles. Thus, 38 articles (CINAHL) and 21 articles (Google Scholar) were reviewed to identify discourses and develop tentative inclusion/exclusion criteria for a second, more focused critical analysis.
1 Identify dominant discourses in practical nurse education literature and 2 Analyze dominant discourses in PN education literature to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Table 1 Canadian provincial and territorial regulatory bodies
LPN regulatory bodies College of Licensed Practical Nurses of British Columbia (CLPNBC) https://clpnbc.org/ College of Licensed Practical Nurses of Alberta (CLPNA) http://www.clpna.com/ Saskatchewan Association of Licensed Practical Nurses (SALPN) http://www.salpn.com/ College of Licensed Practical Nurses of Manitoba (CLPNM) http://www.clpnm.ca/ Registered Practical Nurses Association of Ontario (RPNAO) http://www.rpnao.org/ Ordre des infirmieres et infirmiers auxiliaries du Qu ebec (OIIAQ) http://www.oiiaq.org/ Association of New Brunswick Licensed Practical Nurses (ANBLPN) http://www.anblpn.ca/ College of Licensed Practical Nurses of Nova Scotia (CLPNNS) http://clpnns.ca/ Licensed Practical Nurse Association of Prince Edward Island (LPNAPEI) http://www.lpna.ca/ College of Licensed Practical Nurses of Newfoundland and Labrador (CLPNNL) http://www.clpnnl.ca/ Northwest Territories Department of Health and Social Services (HLTHSS) http://www.hss.gov.nt.ca/professional-licensing/ licensed-practical-nurses RN regulatory bodies College of Registered Nurses of British Columbia (CRNBC) https://crnbc.ca/Pages/Default.aspx College and Association of Registered Nurses of Alberta (CARNA) http://nurses.ab.ca/Carna/index.aspx Saskatchewan Registered Nurses’ Association (SRNA) http://www.srna.org/ College of Registered Nurses of Manitoba (CRNM) http://www.crnm.mb.ca/index.php College of Nurses of Ontario (CNO) http://www.cno.org/ Registered Nurses Association of Ontario (RNAO) http://rnao.ca/ Ordre des infirmieres et infirmiers du Quebec (OIIQ) http://www.oiiq.org/ Nurses Association of New Brunswick (NANB) http://www.nanb.nb.ca/ College of Registered Nurses of Nova Scotia (CRNNS) http://www.crnns.ca/ Association of Registered Nurses of Prince Edward Island (ARNPEI) http://www.arnpei.ca/ Association of Registered Nurses of Newfoundland and Labrador (ARNNL) http://www.arnnl.ca/ Registered Nurses Association of the Northwest Territories and Nunavut (RNANTNU) http://www.rnantnu.ca/ Yukon Registered Nurses Association (YRNA) http://yrna.ca/
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Analytic approach The analysis was underpinned by social constructivism, constructionism and critical theory. Thus, there is an assumption of multiple constructed realities and socially constructed knowledge, which allows and encourages ‘multiple points of view’ (Risjord 2010, 183). Truths do not represent reality, but rather are created socially through interactions among individuals, groups and cultures. Reality is not seen as being mirrored through language; rather, a particular reality is constructed, changed and/or maintained through the use of language and discursive structures (Foucault 1970; Purvis and Hunt 1993; Mills 2010). Thus, we undertook this analysis to expose the constructed truths (assumptions, attitudes and beliefs) that underpin practical nurse education. Further, although discourse can be understood in various ways, we utilized Purvis and Hunt’s (1993) conceptualization of discourse as processes which ‘involve the production of meanings and truth claims’ (497). Discourses both allow and impede certain things to be said, and language (and therefore knowledge) is understood as always contestable. A template utilizing the five questions below guided the analysis: 1 What is said/not said regarding the purpose(s) of practical nurse education? 2 What is said/not said regarding pedagogical approaches which guide practical nurse education? 3 What is said/not said about the relationship between practical and registered nurse education? 4 What is said/not said regarding the role of nursing theory and/or research in practical nurse education? 5 What power relations and dynamics shape the discursive landscape? Who is included/excluded/privileged in these conversations?
Table 2 Literature reviewed for critical analysis Arsenault (1999) Downey (2004) Elliott (1995) Evans (2005) Junk et al. (1995) LaHay (1997) LaHay (1998) Martin Saarinen (2008) Meadows and Prociuk (2012) Morrison et al. (2009) Myers et al. (1997) Plunkett (2007) Robinson (2009) Smith (1995)
therefore, PN education was conceptualized. From this literature, we identified the following predominating themes within the discursive landscape of PN education in Canada. Preregistration PN education literature revealed discourses that focused on the following: (1) the history of PN education; (2) how PN education could address the nursing shortage more efficiently and at a lower cost; (3) preparing students for an expanded scope of practice and the competencies needed for working in acute care; (4) role confusion, ambiguity and conflict within the nursing profession; (5) the need for both interprofessional and intraprofessional collaboration; (6) the need for evidence-based practice; and (7) employers’ views about nurses as human resources and the need for cost containment. There was very little discussion in this literature about our disciplinary/nursing knowledge base or about the educational preparation required for teachers in PN education programs.
CRITICAL ANALYSIS OF THE DISCURSIVE LANDSCAPE OF PN EDUCATION IDENTIFYING DOMINANT DISCOURSES The initial review of 59 articles revealed that much of the literature related to postlicensure PN practice and focused on transitioning from PN practice to RN practice. We decided to only include literature that addressed prelicensure practical nurse education, as well as focusing on Canadian scholarly articles written in English after 1991. Applying the inclusion criteria reduced the number of articles from 59 articles to 14. These 14 articles (Table 2) were then critically reviewed alongside the regulatory documents (Table 1). Interestingly, we found that there was significant variability across the country in terms of how practical nursing, and 234
The five questions listed earlier frame our critical analysis of the purpose of PN education, PN curricula and/or educational programs, the relationship between RN and PN education, the role and importance of disciplinary knowledge (research and theory) and power relations. We first discuss the different ways of framing discussions about the profession(s) and discipline of nursing.
One profession or two or three? Throughout the literature reviewed, there are various interpretations of nursing as a profession(s) and the place and © 2014 John Wiley & Sons Ltd
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relative importance of our disciplinary knowledge. For some writers, nursing is conceptualized as one profession, under which various regulatory groups reside (Myers et al. 1997; LaHay 1998; Canadian Nurses Association 2007; Martin Saarinen 2008). Alternatively, others see practical and registered nursing as separate professions (Junk, Houle and Pong 1995; Downey 2004). Several authors are unclear or do not address whether practical nursing is a separate profession or under one professional umbrella of nursing (Smith 1995; LaHay 1997; Arsenault 1999; Evans 2005; Plunkett 2007; Morrison et al. 2009; Robinson 2009; and Meadows and Prociuk 2012). In British Columbia (Canada’s most Western province), provincial legislation lists registered nursing and practical nursing as separate professions, each with their own college of nurses or regulatory body (British Columbia Ministry of Health 2014). The literature reviewed illuminates various conceptualizations of nursing as one, two or possibly three professions, as registered psychiatric nurses are also regulated separately.
Purpose of practical nurse education The continued need for practical nurses is outlined in discussions about nursing shortages, employer needs, skilled workers and cost/efficiency/economic and historical discourses (Junk et al. 1995; Smith 1995; LaHay 1997, 1998; Arsenault 1999; Downey 2004; Plunkett 2007; Martin Saarinen 2008; Morrison et al. 2009; Robinson 2009; and Meadows and Prociuk 2012). Related to employer needs are predominating discourses about the skilled worker. Governmental initiatives, such as British Columbia’s skilled worker initiative, highlight the need to develop workers whose skills align with economic demands – getting the ‘right skills, in the right place, at the right time’ (Ministry of Regional Economic and Skills Development 2010, 2). This initiative involves supporting various labor market training programs and encourages postsecondary institutions to utilize labor market needs to influence student enrollment processes and curricula. Related to the skilled worker discourse is the argument by Junk and colleagues (1995) that the current workforce demands a shift from the most highly qualified worker to those who are the most appropriately trained, which assists in greater utilization of LPNs in various contexts. Downey (2004) questioned whether current changes to practical nurse curricula reflect movement toward the space created by the phasing out of diploma prepared registered nurses. When the baccalaureate degree became the entry-topractice requirement for registered nurses across Canada, most diploma programs were closed or amalgamated with university programs (Canadian Nurses Association 2004; © 2014 John Wiley & Sons Ltd
Villeneuve 2010). Recent gaps created from the closure of nursing diploma and hospital training programs, in addition to an ageing population and persistent nurse shortages, have created the need for more nurses in acute care. PNs have been increasingly well positioned to step into various roles with expanded scopes of practice. Related to the changing competencies for PNs are conversations about the need for changes to prelicensure PN education to support employer expectations.
Practical nurse curricula/educational programs While the development of the nursing assistant role was initially conceived as a temporary measure, healthcare institutions continued to rely on nursing assistants to supplement nursing staff in a cost-efficient way (Downey 2004; Martin Saarinen 2008). This practice created a rapid proliferation of programs, which resulted in significant variability, declining admission requirements and inadequate curricula (Martin Saarinen 2008). These nursing assistant programs later became practical nursing (PN) educational programs and emphasized basic nursing skills. Currently, there continues to be considerable variability in PN programming related to local contexts influencing expectations for PNs in the workplace. It was noted that past variability in training related to employer needs, in that PN training programs were ‘tailored to meet jurisdictional needs and subsequently offered much variation in content and expectations’ (Canadian Institute of Health Information 2007, 19). Admission requirements for prospective practical nursing students and hours of education (including both theory and practice) vary considerably from program to program (Elliott 1995; Myers et al. 1997; Martin Saarinen 2008; Meadows and Prociuk 2012). Some authors argue that more standardization is needed in practical nurse education. As Downey (2004) asserts, ‘the wide range of theory and clinical practice time required in the PN programs across the provinces – that results in the same credential – is unsettling’ (109). Discussions on changing practice expectations were framed within discourses about altering or expanding scopes of practice and/or the competencies needed for PNs (Elliott 1995; Junk et al. 1995; Smith 1995; LaHay 1997; Arsenault 1999; Downey 2004; Robinson 2009; Meadows and Prociuk 2012). As the legislated role of the PN expands (including roles in acute care), significant change to PN competencies is occurring. While Meadows and Prociuk (2012) call for the need to have clearly defined scopes of practice for RNs and PNs, Robinson (2009) noted that attempts to understand relationships between RN and PN scopes of practice, 235
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standards of practice and other regulatory documents remain difficult as they have been created in isolation from each other. There does not seem to be a common framework for the development of the regulatory documents, which makes differentiation and comparison of RN and PN roles difficult (Robinson 2009). Currently, many RNs teach in PN programs, but little is said in the literature about educational preparation for PN educators. While Morrison and colleagues (2009) suggest that nurses need to be prepared for complex healthcare environments, Downey (2004) notes that there remains a shortage of nursing instructors with too few Master’s and PhD-prepared instructors for all nursing programs, including PN programs. Robinson (2009) states that nursing instructors have little teaching experience and sometimes learn through trial and error. However, the development of ‘nurse thinking’ requires highly skilled instructors who can teach ‘in such a way that know-what and know-how are inextricably connected’ (31). Morrison and colleagues (2009) argue that nurse educators need to be flexible, innovative and provide high-quality educational experiences for nursing students, which hints at potential competencies. However, there is little discussion about the competencies needed for nursing instructors in practical nurse education programs.
Relationships between RN and PN education Robinson (2009) suggests that changes to PN practice have created role confusion between RNs and LPNs, noting that the term ‘nurse’ is confusing to students, as it applies to those with significantly overlapping and as well as distinct knowledge bases. Further, while RNs and PNs are seen to have many overlapping competencies (Meadows and Prociuk 2012), nursing students tend to explain their scope of practice related to tasks performed, as they are unaware of the complexity of the nursing knowledge they utilize in their practice (Martin Saarinen 2008). Robinson (2009) concurs and states that distinctions tend to be made regarding tasks performed. Further, role confusion has created frustration for RNs and PNs and contributes to horizontal violence in the workplace (Meadows and Prociuk 2012). However, other differentiations between RNs and PNs, such as differences in their knowledge base, thinking and reasoning skills, are important to elucidate. As widespread practice change occurs with expanded roles for PNs in acute care, questions are raised about the implications these changes have for both registered and practical nurse education. Significantly, there has been little research available on practical nursing in acute care settings and several authors (Arsenault 1999; Downey 2004; Martin Saarinen 236
2008; Morrison et al. 2009; Robinson 2009; Meadows and Prociuk 2012) note that much more research is needed to identify the effects of integrating practical nurses into various practice contexts. According to some authors, lack of collaboration between nursing groups, regulatory bodies and educational programs is a concern. Downey (2004) and Robinson (2009) suggest that there is little or no collaboration between regulatory groups of nurses, which continues to create both regulatory and educational silos. Robinson (2009) noted that each nursing group is unfamiliar with the others’ scopes of practice and increasing opportunities for collaborative education has the potential for increasing understanding among all nurses. It does seem somewhat perplexing that against the predominating healthcare culture of collaborative practice, there seems to be little collaboration among educators of practical and registered nursing students. Collaboration could potentially be enhanced by intraprofessional arrangements for students as well as for educators to teach in both registered and practical nursing programs (Martin Saarinen 2008). Robinson (2009) advocates for PN-RN bridging programs and having RNs and PNs begin their studies in a common program. Martin Saarinen (2008) also argues for intraprofessional education of RN and PN students through shared classes in the first year of studies and having some educators teach in both programs.
The role and relative importance of nursing knowledge Many questions arose about how nursing leaders conceptualize practical nursing and relationships with the larger, disciplinary landscape of nursing. It was often unclear within provincial and territorial regulatory documents how nursing disciplinary knowledge is shared among the profession(s). There are multiple interpretations of nursing knowledge which raises questions regarding a shared nursing knowledge base. That is, do RNs and LPNs share the disciplinary knowledge of nursing? Authors varied on how explicitly they outline relationships between the discipline of nursing (nursing knowledge) and practical nursing. For example, in her discussion of intraprofessional nursing education, Martin Saarinen (2008) explicitly states that both nursing groups study from the same body of knowledge and that both groups of nurses perform much of the same physical work. Although Morrison et al. (2009) studied simulation learning with practical nursing students, their literature review and discussion only refer
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to nursing and nursing education as a whole, so this seems to suggest a shared knowledge base for all nursing groups. Expectations vary with respect to whether practical nurses utilize nursing knowledge or apply theory in their practice. This variability raises questions about whether practical nursing knowledge is understood as inherently practical and/or atheoretical. However, recent changes to provincial curriculum documents in British Columbia (Project Steering Committee 2011) outline significant philosophical and theoretical underpinnings and explicit theoretical concepts, which would appear to suggest that PN leaders are aligning practical nurse education with nursing disciplinary knowledge. There are also contradictory perspectives related to the role of evidence-based practice and research utilization. Some PN regulatory leaders expect PNs to integrate research and theory into their practice, whereas other regulatory leaders do not include these expectations for PNs. This difference raises the question of assumptions surrounding research and the relative importance of evidence-based practice for practical nursing education. Overall, there seems to be a recognition or assumption that both categories of nurse share a relationship by virtue of a similar knowledge base. However, we discovered differing and ambiguous conceptualizations of nursing, nurse worker categories and nursing education.
Power relations and dynamics This analysis has revealed numerous assumptions, perspectives and tensions surrounding practical nursing education in Canada. Further considerations include power dynamics and whose voices predominate in various conversations. Certainly, there are strong voices from employers who are in need of nurses to care for increasingly complex patients in various care contexts. While economic and skilled worker discourses often dominate nursing discussions, we were also concerned about what discussions are not taking place. While RN program leaders (as well as practical nurse leaders) often focus on conceptualizations of professional practice, leaders of both nursing groups do not often engage together in discussions about nursing education and practice (Robinson 2009). Further, Elliott (1995), in discussions regarding RNs and other healthcare workers (where only RNs are referred to as professionals) reveals how the language of professional can create power differentials among healthcare groups. The movement to have the baccalaureate degree as entry to (professional) nursing practice also creates tension and privileges the status of the RN (registered © 2014 John Wiley & Sons Ltd
nurse) over the two other nursing groups (practical nurses and psychiatric nurses). Power dynamics are reflected in one’s choice of nursing education program as well as where educators choose to teach. How do one’s beliefs about what constitutes a ‘good,’ ‘real’ or ‘professional’ nurse impact a potential student’s choice of nursing program? A critical feminist lens can help to reveal the possible relationships between how women’s work is valued and differing understandings of the knowledge needed for nursing work and the importance of developing nurses’ clinical reasoning skills (Benner et al. 2010). McDonald and McIntyre (2010) observe that the prevailing focus on performing nursing tasks supersedes the emotional and relational work of nurses. Perhaps ‘varying beliefs and assumptions surrounding what constitutes a ‘registered nurse’ and ‘practical nurse’ create and maintain educational silos by virtue of those who choose to educate students within the various programs’ (Butcher 2013, 41), as well as what programs students choose. Thus, even among nurses, there can be differing understandings of ‘what knowledge/skills/attributes are needed to be a nurse, and whether one views nursing as a ‘calling’, an extension of one’s innate ability to care for another, or needing training and/or education’ (Butcher 2013, 32). There remain numerous tensions surrounding relationships, beliefs and assumptions concerning practical nursing which intersect with issues of gender, class and educational hierarchies.
Limitations The intent of engaging in this case analysis was not to arrive at any specific conclusions, but rather to reveal ‘truths’ about practical nurse education and raise critical questions asked as a result of experiences teaching nursing. It is via case knowledge that one can reveal and disrupt other forms of understanding, providing new interpretations of phenomena (Luck, Jackson and Usher 2006). Examining a context-bound case such as ours provides a way to capture experiential paradoxes, complexities and ambiguities, which contribute to accumulating knowledge about nursing education (Flyvbjerg 2006). Changes to healthcare and nursing education are happening internationally, and we invite others to share their experiences, questions or concerns regarding how nursing is evolving. It is hoped that questions raised here will encourage thoughtful reflection and discussion among educators as to possibilities for enhanced communication, transparency, mentoring and collaboration. 237
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CONCLUSIONS
REFERENCES
This historical and critical review of the discursive landscape for practical nurse education in Canada has revealed the enduring nature of practice hierarchies and educational silos in nursing. In Canada, an effort was made to ensure that all registered nurses were prepared at the baccalaureate level to address the expanding knowledge base needed for nursing. However, we have learned that discourses about shifting scopes of practice are framed as differences in technical skills and not as differences in disciplinary knowledge or clinical reasoning. Employer needs, particularly in acute care hospital settings, have resulted in the continuation of diploma prepared registered practical nurses. The lack of collaborative relationships among professional, educational and regulatory nursing groups is concerning due to predictions about global shortages of nurses and nursing educators in the future. This case study is intended to stimulate thoughtful conversations regarding the significance of conceptualizing nursing as one or more profession(s) and how this may impact the relationship of PN education to the discipline of nursing. Additional questions to explore include the following: What groups are utilizing nursing knowledge for practice, and how might that be determined? What evidence do we currently have, and what evidence might be needed to provide safe and effective nursing care to individuals, groups and society? What impact do various conceptualizations of profession, discipline, nursing, training, education and practical have in how we understand nursing? How might educational silos perpetuate certain power relations and inequities between nurses and nursing students? The identified discourses highlight the socially negotiated and changing nature of nursing work. Certain constructed truths can result in patterns of existence that limit new possibilities. More research is needed to explore the shifting landscape of nursing and the effects that current changes to scope and skill mix may have on patient care. Analyzing practical nursing education discourses using a critical lens allows for further exploration of relationships among language, truth and power and how they influence the dissemination and uptake of knowledge. Thus, nurses, educators, leaders and regulators must engage in discussions and further research to determine best practices for nursing practice and education. The future of the nursing profession and discipline is at stake.
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practical nursing program. Clinical Simulation in Nursing 5: e67–71. Myers A, N Keat, C Pelkman and S French. 1997. Applications to B.Sc.N., R.N., and R.P.N. nursing programs: Differences and predictors. Canadian Journal of Nursing Research 29: 113–21. Nursing and Midwifery Council. 2004. Standards and proficiency for pre-registration nursing education. http://www. nmc-uk.org/Documents/Standards/nmcStandardsofProficiencyForPre_RegistrationNursingEducation.pdf (accessed 24 October 2014) Plunkett M. 2007. Beausoleil first nations project on Christian Island: Loyalist College, Bancroft Campus Practical Nursing Program. Aboriginal Nurse 4: 8–9. Project Steering Committee. 2011. Practical nursing program provincial curriculum. Burnaby, BC: Project Steering Committee. Purvis T and A Hunt. 1993. Discourse, ideology, discourse, ideology, discourse, ideology. . . British Journal of Sociology 44: 473–99. Risjord M. 2010. Nursing knowledge: Science, practice, and philosophy. West Sussex, UK: Wiley-Blackwell. Robinson M. 2009. Knowledge and education at entry to nursing practice in Alberta. KEP Steering Committee. Edmonton, AB: CARNA. Scaia M and K McPherson. 2010. Challenges and change in undergraduate education. In Realities of Canadian nursing, 3rd edn, eds M McIntyre and C McDonald, 183–202. New York: Lippincott Williams & Wilkins. Smith L. 1995. Breaking a mindset. Care Connection 10: 5. Thorne S. 2012. What’s in a case? Nursing Inquiry 19: 281–2. Villeneuve MJ. 2010. The Canadian nurses association and the international council of nurses. In Realities of Canadian nursing, 3rd edn, eds M McIntyre and C McDonald, 117–46. New York: Lippincott Williams & Wilkins.
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Educational silos in nursing education: a critical review of practical nurse education in Canada Diane L Butchera and Karen A MacKinnonb aUniversity of Victoria, Victoria, BC, Canada, bSchool of Nursing, University of Victoria, Victoria, BC, Canada Accepted for publication 7 November 2014 DOI: 10.1111/nin.12090
BUTCHER DL and MACKINNON KA. Nursing Inquiry 2015; 22: 231–239 Educational silos in nursing education: a critical review of practical nurse education in Canada Changes to practical nurse education (with expanded scopes of practice) align with the increasing need for nurses and assistive personnel in global acute care contexts. A case in point is this critical exploration of Canadian practical nursing literature, undertaken to reveal predominating discourses and relationships to nursing disciplinary knowledge. The objectives of this poststructural critical review were to identify dominant discourses in practical nurse education literature and to analyze these discourses to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Predominant themes in the discourses surrounding practical nurse education included conversations about the nurse shortage, expanded roles, collaboration, evidence-based practice, role confusion, cost/efficiency, the history of practical nurse education and employer interests. The complex relationships between practical nursing and the disciplinary landscape of nursing are revealed in the analysis of discourses related to the purpose(s) of practical nurse education, curricula/ educational programming, relationships between RN and PN education and the role of nursing knowledge. Power dynamics related to employer needs and interests, as well as educational silos and the nature of women’s work, are also revealed within the intersection of various discourses. Key words: critical theory, discourse, education, nursing, history of nursing, power, practical nursing.
The first author’s experiences teaching in a practical nurse (PN) program while concurrently enrolled in graduate school raised concerns surrounding relationships between nursing knowledge and practical nursing education. In addition, the recent introduction of new staffing models in hospitals in our provincial context is aligning with rapid expansion and changes to PN education and practice, including expanded roles within acute care hospital settings. Having experienced these changes through work in teaching PN students, questions emerged that were the impetus for the first author’s graduate school project – a critical analysis of practical nurse education in Canada (Butcher 2013). The purpose of this current discussion is to present a case study to review Correspondence: Diane L. Butcher, PhD Student, University of Victoria, Victoria, BC, Canada. E-mail: © 2014 John Wiley & Sons Ltd
and critically analyze discourses in Canadian practical nurse education literature to uncover underlying beliefs and assumptions, tensions and ambiguities, sources of knowledge and constructed truths. It is through this ‘interpretive vehicle’ (Thorne 2012, 281) of analysis of our case that we can add to accumulating knowledge related to global discussions of the need for nurses and assistive personnel in health-care.
HISTORICAL BACKGROUND From the expansion of North American British Colonies in the 1800s to the current context of nursing in Canada, the term ‘nurse’ has continued to refer to a ‘range of practitioners with a range of training and experience’ (Scaia and McPherson 2010, 195). Many early 19th century Catholic nuns held significant expertise as nurses and nurse
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administrators and often apprenticed under Europeantrained physicians. Lay nurses and midwives with less formal education were available for hire to provide care for middleand upper-class families and ‘sought to distinguish themselves from domestic servants, nannies or even governesses’ (Scaia and McPherson 2010, 195). While caregivers in hospitals were often aligned with the servant class, the growth of hospitals in the latter half of the 19th century created a demand for more nurses with greater skills. The expansion of hospitals, as well as discourses of physicians as medical experts, resulted in hospitals that were organized to suit medical practice (Martin Saarinen 2008). While needing skilled nurses, costs were a concern, as hospitals relied on significant financial support from the government and charitable funding. Administrators, ‘in keeping with the ideology of the born nurse, were reluctant to pay a fair wage for work that was considered an extension of domestic services’ (Martin Saarinen 2008, 19). In England, Florence Nightingale also believed that nurses performed duties that came naturally to all women. Nightingale encouraged women from upper classes of society to train for nursing management positions, while women from lower classes of society were to provide direct patient care under supervision. Thus, a hierarchy was beginning to emerge within the nursing landscape (Martin Saarinen 2008; Scaia and McPherson 2010). The Great Depression early in the 20th century (1929– 1933) created difficulties for many nurses to find employment. However, large numbers of nurses enlisted and served with the Canadian Armed Forces during World War II (1939–1945). As a result, concerns were raised about pending shortages of Canadian nurses, so the government increased funding to support enrollments in university and hospital-based nursing programs (Martin Saarinen 2008). Shorter educational programs to prepare nursing assistants were originally designed as a temporary measure to offset nursing shortages during the war. Martin Saarinen (2008) notes how governments planned to disband the programs once registered nurses returned to their civilian duties. However, RN shortages persisted after the war (partly due to the baby boom), and these shorter programs continued. Martin Saarinen (2008) observed that economics contributed to the continued employment of nursing assistants such as nurses aides and later practical nurses. Practical nurses (PNs) also graduated faster, entered the workforce more quickly and were paid a lower wage than the RN. Thus, throughout Canada, practical nurses continued to work where there were shortages of RNs (such as in residential care facilities), while RNs predominated in acute care 232
hospitals. However, persisting shortages of RNs over recent decades (created in part by the closure of RN diploma programs in support of the baccalaureate degree as entry to practice) have contributed to shifts in expectations for practical nurses. Many PN diploma programs have recently been revised (from one- to two-year programs) to prepare practical nurses for expanded scopes of practice and for working in acute care settings alongside RNs. As practical nurses are registered by Colleges of Nursing in most Canadian provinces, the designation registered nurse now has a more ambiguous meaning. In Canada today, there are three regulated groups of nurses – registered nurses (RNs), licensed or registered practical nurses (LPNs or RPNs) and registered psychiatric nurses (also RPNs). In most provinces and territories, the title LPN (licensed practical nurse) is protected. However, in Ontario, the term ‘RPN’ (registered practical nurse) is used. To avoid confusion, we will use the term ‘PN’ (practical nurse) or PN education to refer to both licensed and registered practical nurses. Registered psychiatric nurses are found primarily in Western Canada. As this review focuses on practical nurse (PN) education, we have not explored documents about registered psychiatric nurses. Significant global workforce shortages have also created the need for both regulated and unregulated assistive nursing personnel beyond Canada (American Association of Colleges of Nursing 2014). In the UK, registered nurses include first-level nurses (RNs) and second-level nurses (enrolled nurses). Enrolled/diploma nurse training is no longer provided in the UK; however, ENs can still be licensed to work as nurses (Nursing and Midwifery Council 2004). As in Canada, unregulated healthcare aides also provide nursing care. In the United States, LPNs (also known as licensed vocational nurses) are registered, in addition to RNs who are prepared through diploma, associate degree or baccalaureate degree programs (American Association of Colleges of Nursing 2014). In Australia, vocational or diploma nurses are referred to as enrolled nurses and RNs receive a baccalaureate degree for practice (Australian Institute of Health and Welfare 2013). Throughout the world, numerous titles are also utilized for unregulated personnel (such as healthcare aides, nursing assistants, nurse auxiliary) who also provide nursing care (Canadian Nurses Association 2005). The complexity of the nursing landscape raises important questions about practical or vocational nursing knowledge. How is practical nursing knowledge related to the larger discipline of nursing? Is this relationship made explicit? If practical nursing education draws on nursing disciplinary knowledge, should/does nursing literature inform practical nurse curricula, educators and practice? © 2014 John Wiley & Sons Ltd
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METHODOLOGY
Literature search strategy
A preliminary review of Canadian regulatory documents for both registered nurses and practical nurses (Table 1) provided the foundation for further analysis. This critical review of provincial and territorial regulatory Web sites of both registered nurses (RNs) and practical nurses (LPNs and RPNs) helped to elucidate whether relationships between registered and practical nursing knowledge were made explicit in various regulatory documents. Iteratively, a broader literature review was then performed to review the larger discursive landscape. The objectives of this poststructural critical review were to do the following:
To identify and analyze the predominating discourses, a dialectical and iterative approach was undertaken. Searching the library databases (CINAHL and Google Scholar) revealed 59 articles. Utilizing search terms ‘practical nurs*,’ ‘canad*,’ ‘education’ and ‘scholarly’ in the CINAHL database yielded 37 articles. Substituting ‘vocational’ for the term ‘practical’ in the original search yielded two repeat articles from the original search. Searching CINAHL with terms ‘practical nurs*,’ ‘canad*’ and ‘curricu*’ produced one article. Searching the Google Scholar database using terms ‘licensed practical nurse education’ and Canada produced 23 articles. Adding the search term ‘curriculum’ produced 14 articles from the Google Scholar database. Removing duplicates from the two Google Scholar searches resulted in 21 articles. Thus, 38 articles (CINAHL) and 21 articles (Google Scholar) were reviewed to identify discourses and develop tentative inclusion/exclusion criteria for a second, more focused critical analysis.
1 Identify dominant discourses in practical nurse education literature and 2 Analyze dominant discourses in PN education literature to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Table 1 Canadian provincial and territorial regulatory bodies
LPN regulatory bodies College of Licensed Practical Nurses of British Columbia (CLPNBC) https://clpnbc.org/ College of Licensed Practical Nurses of Alberta (CLPNA) http://www.clpna.com/ Saskatchewan Association of Licensed Practical Nurses (SALPN) http://www.salpn.com/ College of Licensed Practical Nurses of Manitoba (CLPNM) http://www.clpnm.ca/ Registered Practical Nurses Association of Ontario (RPNAO) http://www.rpnao.org/ Ordre des infirmieres et infirmiers auxiliaries du Qu ebec (OIIAQ) http://www.oiiaq.org/ Association of New Brunswick Licensed Practical Nurses (ANBLPN) http://www.anblpn.ca/ College of Licensed Practical Nurses of Nova Scotia (CLPNNS) http://clpnns.ca/ Licensed Practical Nurse Association of Prince Edward Island (LPNAPEI) http://www.lpna.ca/ College of Licensed Practical Nurses of Newfoundland and Labrador (CLPNNL) http://www.clpnnl.ca/ Northwest Territories Department of Health and Social Services (HLTHSS) http://www.hss.gov.nt.ca/professional-licensing/ licensed-practical-nurses RN regulatory bodies College of Registered Nurses of British Columbia (CRNBC) https://crnbc.ca/Pages/Default.aspx College and Association of Registered Nurses of Alberta (CARNA) http://nurses.ab.ca/Carna/index.aspx Saskatchewan Registered Nurses’ Association (SRNA) http://www.srna.org/ College of Registered Nurses of Manitoba (CRNM) http://www.crnm.mb.ca/index.php College of Nurses of Ontario (CNO) http://www.cno.org/ Registered Nurses Association of Ontario (RNAO) http://rnao.ca/ Ordre des infirmieres et infirmiers du Quebec (OIIQ) http://www.oiiq.org/ Nurses Association of New Brunswick (NANB) http://www.nanb.nb.ca/ College of Registered Nurses of Nova Scotia (CRNNS) http://www.crnns.ca/ Association of Registered Nurses of Prince Edward Island (ARNPEI) http://www.arnpei.ca/ Association of Registered Nurses of Newfoundland and Labrador (ARNNL) http://www.arnnl.ca/ Registered Nurses Association of the Northwest Territories and Nunavut (RNANTNU) http://www.rnantnu.ca/ Yukon Registered Nurses Association (YRNA) http://yrna.ca/
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Analytic approach The analysis was underpinned by social constructivism, constructionism and critical theory. Thus, there is an assumption of multiple constructed realities and socially constructed knowledge, which allows and encourages ‘multiple points of view’ (Risjord 2010, 183). Truths do not represent reality, but rather are created socially through interactions among individuals, groups and cultures. Reality is not seen as being mirrored through language; rather, a particular reality is constructed, changed and/or maintained through the use of language and discursive structures (Foucault 1970; Purvis and Hunt 1993; Mills 2010). Thus, we undertook this analysis to expose the constructed truths (assumptions, attitudes and beliefs) that underpin practical nurse education. Further, although discourse can be understood in various ways, we utilized Purvis and Hunt’s (1993) conceptualization of discourse as processes which ‘involve the production of meanings and truth claims’ (497). Discourses both allow and impede certain things to be said, and language (and therefore knowledge) is understood as always contestable. A template utilizing the five questions below guided the analysis: 1 What is said/not said regarding the purpose(s) of practical nurse education? 2 What is said/not said regarding pedagogical approaches which guide practical nurse education? 3 What is said/not said about the relationship between practical and registered nurse education? 4 What is said/not said regarding the role of nursing theory and/or research in practical nurse education? 5 What power relations and dynamics shape the discursive landscape? Who is included/excluded/privileged in these conversations?
Table 2 Literature reviewed for critical analysis Arsenault (1999) Downey (2004) Elliott (1995) Evans (2005) Junk et al. (1995) LaHay (1997) LaHay (1998) Martin Saarinen (2008) Meadows and Prociuk (2012) Morrison et al. (2009) Myers et al. (1997) Plunkett (2007) Robinson (2009) Smith (1995)
therefore, PN education was conceptualized. From this literature, we identified the following predominating themes within the discursive landscape of PN education in Canada. Preregistration PN education literature revealed discourses that focused on the following: (1) the history of PN education; (2) how PN education could address the nursing shortage more efficiently and at a lower cost; (3) preparing students for an expanded scope of practice and the competencies needed for working in acute care; (4) role confusion, ambiguity and conflict within the nursing profession; (5) the need for both interprofessional and intraprofessional collaboration; (6) the need for evidence-based practice; and (7) employers’ views about nurses as human resources and the need for cost containment. There was very little discussion in this literature about our disciplinary/nursing knowledge base or about the educational preparation required for teachers in PN education programs.
CRITICAL ANALYSIS OF THE DISCURSIVE LANDSCAPE OF PN EDUCATION IDENTIFYING DOMINANT DISCOURSES The initial review of 59 articles revealed that much of the literature related to postlicensure PN practice and focused on transitioning from PN practice to RN practice. We decided to only include literature that addressed prelicensure practical nurse education, as well as focusing on Canadian scholarly articles written in English after 1991. Applying the inclusion criteria reduced the number of articles from 59 articles to 14. These 14 articles (Table 2) were then critically reviewed alongside the regulatory documents (Table 1). Interestingly, we found that there was significant variability across the country in terms of how practical nursing, and 234
The five questions listed earlier frame our critical analysis of the purpose of PN education, PN curricula and/or educational programs, the relationship between RN and PN education, the role and importance of disciplinary knowledge (research and theory) and power relations. We first discuss the different ways of framing discussions about the profession(s) and discipline of nursing.
One profession or two or three? Throughout the literature reviewed, there are various interpretations of nursing as a profession(s) and the place and © 2014 John Wiley & Sons Ltd
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relative importance of our disciplinary knowledge. For some writers, nursing is conceptualized as one profession, under which various regulatory groups reside (Myers et al. 1997; LaHay 1998; Canadian Nurses Association 2007; Martin Saarinen 2008). Alternatively, others see practical and registered nursing as separate professions (Junk, Houle and Pong 1995; Downey 2004). Several authors are unclear or do not address whether practical nursing is a separate profession or under one professional umbrella of nursing (Smith 1995; LaHay 1997; Arsenault 1999; Evans 2005; Plunkett 2007; Morrison et al. 2009; Robinson 2009; and Meadows and Prociuk 2012). In British Columbia (Canada’s most Western province), provincial legislation lists registered nursing and practical nursing as separate professions, each with their own college of nurses or regulatory body (British Columbia Ministry of Health 2014). The literature reviewed illuminates various conceptualizations of nursing as one, two or possibly three professions, as registered psychiatric nurses are also regulated separately.
Purpose of practical nurse education The continued need for practical nurses is outlined in discussions about nursing shortages, employer needs, skilled workers and cost/efficiency/economic and historical discourses (Junk et al. 1995; Smith 1995; LaHay 1997, 1998; Arsenault 1999; Downey 2004; Plunkett 2007; Martin Saarinen 2008; Morrison et al. 2009; Robinson 2009; and Meadows and Prociuk 2012). Related to employer needs are predominating discourses about the skilled worker. Governmental initiatives, such as British Columbia’s skilled worker initiative, highlight the need to develop workers whose skills align with economic demands – getting the ‘right skills, in the right place, at the right time’ (Ministry of Regional Economic and Skills Development 2010, 2). This initiative involves supporting various labor market training programs and encourages postsecondary institutions to utilize labor market needs to influence student enrollment processes and curricula. Related to the skilled worker discourse is the argument by Junk and colleagues (1995) that the current workforce demands a shift from the most highly qualified worker to those who are the most appropriately trained, which assists in greater utilization of LPNs in various contexts. Downey (2004) questioned whether current changes to practical nurse curricula reflect movement toward the space created by the phasing out of diploma prepared registered nurses. When the baccalaureate degree became the entry-topractice requirement for registered nurses across Canada, most diploma programs were closed or amalgamated with university programs (Canadian Nurses Association 2004; © 2014 John Wiley & Sons Ltd
Villeneuve 2010). Recent gaps created from the closure of nursing diploma and hospital training programs, in addition to an ageing population and persistent nurse shortages, have created the need for more nurses in acute care. PNs have been increasingly well positioned to step into various roles with expanded scopes of practice. Related to the changing competencies for PNs are conversations about the need for changes to prelicensure PN education to support employer expectations.
Practical nurse curricula/educational programs While the development of the nursing assistant role was initially conceived as a temporary measure, healthcare institutions continued to rely on nursing assistants to supplement nursing staff in a cost-efficient way (Downey 2004; Martin Saarinen 2008). This practice created a rapid proliferation of programs, which resulted in significant variability, declining admission requirements and inadequate curricula (Martin Saarinen 2008). These nursing assistant programs later became practical nursing (PN) educational programs and emphasized basic nursing skills. Currently, there continues to be considerable variability in PN programming related to local contexts influencing expectations for PNs in the workplace. It was noted that past variability in training related to employer needs, in that PN training programs were ‘tailored to meet jurisdictional needs and subsequently offered much variation in content and expectations’ (Canadian Institute of Health Information 2007, 19). Admission requirements for prospective practical nursing students and hours of education (including both theory and practice) vary considerably from program to program (Elliott 1995; Myers et al. 1997; Martin Saarinen 2008; Meadows and Prociuk 2012). Some authors argue that more standardization is needed in practical nurse education. As Downey (2004) asserts, ‘the wide range of theory and clinical practice time required in the PN programs across the provinces – that results in the same credential – is unsettling’ (109). Discussions on changing practice expectations were framed within discourses about altering or expanding scopes of practice and/or the competencies needed for PNs (Elliott 1995; Junk et al. 1995; Smith 1995; LaHay 1997; Arsenault 1999; Downey 2004; Robinson 2009; Meadows and Prociuk 2012). As the legislated role of the PN expands (including roles in acute care), significant change to PN competencies is occurring. While Meadows and Prociuk (2012) call for the need to have clearly defined scopes of practice for RNs and PNs, Robinson (2009) noted that attempts to understand relationships between RN and PN scopes of practice, 235
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standards of practice and other regulatory documents remain difficult as they have been created in isolation from each other. There does not seem to be a common framework for the development of the regulatory documents, which makes differentiation and comparison of RN and PN roles difficult (Robinson 2009). Currently, many RNs teach in PN programs, but little is said in the literature about educational preparation for PN educators. While Morrison and colleagues (2009) suggest that nurses need to be prepared for complex healthcare environments, Downey (2004) notes that there remains a shortage of nursing instructors with too few Master’s and PhD-prepared instructors for all nursing programs, including PN programs. Robinson (2009) states that nursing instructors have little teaching experience and sometimes learn through trial and error. However, the development of ‘nurse thinking’ requires highly skilled instructors who can teach ‘in such a way that know-what and know-how are inextricably connected’ (31). Morrison and colleagues (2009) argue that nurse educators need to be flexible, innovative and provide high-quality educational experiences for nursing students, which hints at potential competencies. However, there is little discussion about the competencies needed for nursing instructors in practical nurse education programs.
Relationships between RN and PN education Robinson (2009) suggests that changes to PN practice have created role confusion between RNs and LPNs, noting that the term ‘nurse’ is confusing to students, as it applies to those with significantly overlapping and as well as distinct knowledge bases. Further, while RNs and PNs are seen to have many overlapping competencies (Meadows and Prociuk 2012), nursing students tend to explain their scope of practice related to tasks performed, as they are unaware of the complexity of the nursing knowledge they utilize in their practice (Martin Saarinen 2008). Robinson (2009) concurs and states that distinctions tend to be made regarding tasks performed. Further, role confusion has created frustration for RNs and PNs and contributes to horizontal violence in the workplace (Meadows and Prociuk 2012). However, other differentiations between RNs and PNs, such as differences in their knowledge base, thinking and reasoning skills, are important to elucidate. As widespread practice change occurs with expanded roles for PNs in acute care, questions are raised about the implications these changes have for both registered and practical nurse education. Significantly, there has been little research available on practical nursing in acute care settings and several authors (Arsenault 1999; Downey 2004; Martin Saarinen 236
2008; Morrison et al. 2009; Robinson 2009; Meadows and Prociuk 2012) note that much more research is needed to identify the effects of integrating practical nurses into various practice contexts. According to some authors, lack of collaboration between nursing groups, regulatory bodies and educational programs is a concern. Downey (2004) and Robinson (2009) suggest that there is little or no collaboration between regulatory groups of nurses, which continues to create both regulatory and educational silos. Robinson (2009) noted that each nursing group is unfamiliar with the others’ scopes of practice and increasing opportunities for collaborative education has the potential for increasing understanding among all nurses. It does seem somewhat perplexing that against the predominating healthcare culture of collaborative practice, there seems to be little collaboration among educators of practical and registered nursing students. Collaboration could potentially be enhanced by intraprofessional arrangements for students as well as for educators to teach in both registered and practical nursing programs (Martin Saarinen 2008). Robinson (2009) advocates for PN-RN bridging programs and having RNs and PNs begin their studies in a common program. Martin Saarinen (2008) also argues for intraprofessional education of RN and PN students through shared classes in the first year of studies and having some educators teach in both programs.
The role and relative importance of nursing knowledge Many questions arose about how nursing leaders conceptualize practical nursing and relationships with the larger, disciplinary landscape of nursing. It was often unclear within provincial and territorial regulatory documents how nursing disciplinary knowledge is shared among the profession(s). There are multiple interpretations of nursing knowledge which raises questions regarding a shared nursing knowledge base. That is, do RNs and LPNs share the disciplinary knowledge of nursing? Authors varied on how explicitly they outline relationships between the discipline of nursing (nursing knowledge) and practical nursing. For example, in her discussion of intraprofessional nursing education, Martin Saarinen (2008) explicitly states that both nursing groups study from the same body of knowledge and that both groups of nurses perform much of the same physical work. Although Morrison et al. (2009) studied simulation learning with practical nursing students, their literature review and discussion only refer
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to nursing and nursing education as a whole, so this seems to suggest a shared knowledge base for all nursing groups. Expectations vary with respect to whether practical nurses utilize nursing knowledge or apply theory in their practice. This variability raises questions about whether practical nursing knowledge is understood as inherently practical and/or atheoretical. However, recent changes to provincial curriculum documents in British Columbia (Project Steering Committee 2011) outline significant philosophical and theoretical underpinnings and explicit theoretical concepts, which would appear to suggest that PN leaders are aligning practical nurse education with nursing disciplinary knowledge. There are also contradictory perspectives related to the role of evidence-based practice and research utilization. Some PN regulatory leaders expect PNs to integrate research and theory into their practice, whereas other regulatory leaders do not include these expectations for PNs. This difference raises the question of assumptions surrounding research and the relative importance of evidence-based practice for practical nursing education. Overall, there seems to be a recognition or assumption that both categories of nurse share a relationship by virtue of a similar knowledge base. However, we discovered differing and ambiguous conceptualizations of nursing, nurse worker categories and nursing education.
Power relations and dynamics This analysis has revealed numerous assumptions, perspectives and tensions surrounding practical nursing education in Canada. Further considerations include power dynamics and whose voices predominate in various conversations. Certainly, there are strong voices from employers who are in need of nurses to care for increasingly complex patients in various care contexts. While economic and skilled worker discourses often dominate nursing discussions, we were also concerned about what discussions are not taking place. While RN program leaders (as well as practical nurse leaders) often focus on conceptualizations of professional practice, leaders of both nursing groups do not often engage together in discussions about nursing education and practice (Robinson 2009). Further, Elliott (1995), in discussions regarding RNs and other healthcare workers (where only RNs are referred to as professionals) reveals how the language of professional can create power differentials among healthcare groups. The movement to have the baccalaureate degree as entry to (professional) nursing practice also creates tension and privileges the status of the RN (registered © 2014 John Wiley & Sons Ltd
nurse) over the two other nursing groups (practical nurses and psychiatric nurses). Power dynamics are reflected in one’s choice of nursing education program as well as where educators choose to teach. How do one’s beliefs about what constitutes a ‘good,’ ‘real’ or ‘professional’ nurse impact a potential student’s choice of nursing program? A critical feminist lens can help to reveal the possible relationships between how women’s work is valued and differing understandings of the knowledge needed for nursing work and the importance of developing nurses’ clinical reasoning skills (Benner et al. 2010). McDonald and McIntyre (2010) observe that the prevailing focus on performing nursing tasks supersedes the emotional and relational work of nurses. Perhaps ‘varying beliefs and assumptions surrounding what constitutes a ‘registered nurse’ and ‘practical nurse’ create and maintain educational silos by virtue of those who choose to educate students within the various programs’ (Butcher 2013, 41), as well as what programs students choose. Thus, even among nurses, there can be differing understandings of ‘what knowledge/skills/attributes are needed to be a nurse, and whether one views nursing as a ‘calling’, an extension of one’s innate ability to care for another, or needing training and/or education’ (Butcher 2013, 32). There remain numerous tensions surrounding relationships, beliefs and assumptions concerning practical nursing which intersect with issues of gender, class and educational hierarchies.
Limitations The intent of engaging in this case analysis was not to arrive at any specific conclusions, but rather to reveal ‘truths’ about practical nurse education and raise critical questions asked as a result of experiences teaching nursing. It is via case knowledge that one can reveal and disrupt other forms of understanding, providing new interpretations of phenomena (Luck, Jackson and Usher 2006). Examining a context-bound case such as ours provides a way to capture experiential paradoxes, complexities and ambiguities, which contribute to accumulating knowledge about nursing education (Flyvbjerg 2006). Changes to healthcare and nursing education are happening internationally, and we invite others to share their experiences, questions or concerns regarding how nursing is evolving. It is hoped that questions raised here will encourage thoughtful reflection and discussion among educators as to possibilities for enhanced communication, transparency, mentoring and collaboration. 237
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CONCLUSIONS
REFERENCES
This historical and critical review of the discursive landscape for practical nurse education in Canada has revealed the enduring nature of practice hierarchies and educational silos in nursing. In Canada, an effort was made to ensure that all registered nurses were prepared at the baccalaureate level to address the expanding knowledge base needed for nursing. However, we have learned that discourses about shifting scopes of practice are framed as differences in technical skills and not as differences in disciplinary knowledge or clinical reasoning. Employer needs, particularly in acute care hospital settings, have resulted in the continuation of diploma prepared registered practical nurses. The lack of collaborative relationships among professional, educational and regulatory nursing groups is concerning due to predictions about global shortages of nurses and nursing educators in the future. This case study is intended to stimulate thoughtful conversations regarding the significance of conceptualizing nursing as one or more profession(s) and how this may impact the relationship of PN education to the discipline of nursing. Additional questions to explore include the following: What groups are utilizing nursing knowledge for practice, and how might that be determined? What evidence do we currently have, and what evidence might be needed to provide safe and effective nursing care to individuals, groups and society? What impact do various conceptualizations of profession, discipline, nursing, training, education and practical have in how we understand nursing? How might educational silos perpetuate certain power relations and inequities between nurses and nursing students? The identified discourses highlight the socially negotiated and changing nature of nursing work. Certain constructed truths can result in patterns of existence that limit new possibilities. More research is needed to explore the shifting landscape of nursing and the effects that current changes to scope and skill mix may have on patient care. Analyzing practical nursing education discourses using a critical lens allows for further exploration of relationships among language, truth and power and how they influence the dissemination and uptake of knowledge. Thus, nurses, educators, leaders and regulators must engage in discussions and further research to determine best practices for nursing practice and education. The future of the nursing profession and discipline is at stake.
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