PROFESSIONAL SURVIVAL: Adjusting to Academia by Degrees BY EVELYN R. BARRITT
I
had a difficult time deciding on a title for this pres entation. There were other titles I considered, such as "Doctors are not the only doctors in health care," or "Everything I've always wan ted to know about colleges of pharmacy but was afraid to ask." At one paint, I decided the topic should be "Misery loves company," but then I decided the best title was "But some of my best friends are pharmacists." I plan to approach the topic first giving historical overviews of pharmacy and nursing. From there, I will look at academic pharmacy and nursing as they exist today, will consider many of our present
Evelyn R. Barritt, RN, PhD, is Dean and professor of Nursing at the College of Nursing, University of Iowa, Iowa City, Iowa 52242. This article is based on Dr. Barritt's presentation to the Council of Deans, American Association of Colleges of Pharmacy, on March 1, 1978, in Kansas City, Missouri. The meeting, an open hearing, focused on the types of pharmacy personnel required to meet society's future needs and included ample discussion of the "one degree controversy" (BS in pharmacy and/or doctor of pharmacy). It is expected that the AACP will make a final recommendation on that controversy at its annual meeting july 16-20, 1978, in Orlando, Florida. For copies of Dr. Barritt's references and resources, contact the editor of American Ph arm
problems, and will close by predicting the future for both academic pharmacy and academic nursing.
Historical Overview of Pharmacy For the pre-Judea-Christian era, there are few written records to consult on the practice of pharmacy. Myths and folklore provide . some evidence of the fact that there was plant gathering for use in the medication and treatment of animals and human beings, but there is no evidence of there being a science of pharmacy. The Wellcome Medical Museum in London portrays pharmacy as an advanced art in ancient Arabia, but there is no evidence of pharmacy being considered a science with systematic investigation of outcomes. From the sixth to fourteenth centuries in Europe, pharmacy appears to have been a part of medicine, not a separate entity. In 1240 Emperor Frederick II issued the edict, your Magna Charta of Pharmacy, that (1) there would be a separation of the pharmaceutical profession from the medical profession, (2) there would be official supervision of the practice of pharmacy, (3) there would be a limited number of pharmacies, and (4) prices would be fixed as would the use of a prescribed formulary. In the fourteenth century in Europe, pharmacists began to be
+ 24
called apothecaries. By 1618 in London, to be a pharmacist one had to have a seven-year apprenticeship. In 1770 the Spanish governor of Louisiana again separated medicine from pharmacy, declaring that there were three separate professionsmedicine, surgery and pharmacy. In 1821 in Philadelphia, the Philadelphia College of Pharmacy was begun; it was not a college in our sense at all, but merely a trade school. The history of pharmacy in the Civil War period is interesting in that at Baldwin University in 1865, pharmaceu-· tical instruction was begun as a part of general education. In 1868 the University of Michigan began the first full course of study in pharmacy, and in 1883 the University of Wisconsin began the first four-year program. In 1902 the first PhD program in pharmacy was begun, also at the University of Wisconsin. In the meantime, various groups and individuals in pharmacy conducted many
'·-A .
American Pharmacy Voi .NS18, No . 6, June 1978/ 304
surveys and studies asking questions such as the who, when, where, why and why not of academic pharmacy. Control of preparation for professional status was a problem area. Programs in pharmacy during the post-Civil War years and on in to the early 1900s ranged from threemonth programs to one-, two-, three-, four-, five-, and six-year programs. One could choose from among correspondence schools, cramming schools, and "diploma mills." (For $100 you could even receive a doctor of pharmacy degree that did not show that it came from a printing company.) Many pharmacists merely received on-the-job training as drug clerks, later calling themselves pharmacists, or as their customers called them, "doc." The history of academic pharmacy in America shows a wide assortment of other problems as well: state boards; reciprocity (endorsement); the use of pharmacy ass is tan ts, associates, and technicians; pharmacy practice; curriculum (both undergraduate and graduate); student selection; funding; physical plant; clinical issues; continuing education; a sense of mission; internship; research; and problems with those in the ranks holding anti-intellectual and antischolar ideas . Pharmacy and nursing could be viewed as the "Bobbsey Twins" of the academic world. According to the literature, nursing perhaps has more sexist problems along with some medical chauvinism problems, though phar-
macy seems to have felt a certain amount of medical chauvinism also.
Historical Overview of Nursing Turning again to pre-Judea-Christian culture, which seems to have been a matriarchal society, we find no written records of the history of nursing or of health practices. We have the linguistic remnant, however, of a class of feminine-gender words that evolved from the culture, such as faith, hope, mercy, intellect, rectitude, spirit, soul, freedom, charity and joy, which signify nurturant activities. Nurturing is what the profession of nursing is all about. There is a dearth of knowledge of nursing history in such places as Africa, Asia, and Central and South America, and so our · knowledge of our own professional history is decidedly limited to the Judea-Christian era in Europe and surrounding nations. It has long been my belief that many minorities, in particular women, blacks and nurses, have not valued their histories and have not produced their share of historiographers who would help to understand and value the past. As is often pointed out, those who do not know their history are bound to make the same mistakes in the future. Be that as it may, generally speaking, the history of nursing shows two widely divergent roots for its practice, one form of nursing coming from the Christian nuns and monks and another form coming from camp followers, prostitutes and derelicts. With tongue in cheek, one could probably state that one group specialized in the bodies and the other group specialized in the souls.
The Nightingale Influence It was not until the 1860s at St.
American Pharmacy Vo i. NS18 , No . 6 , Jun e 1978/ 305
Thomas Hospital in London that Florence Nightingale devised a systematic and scientific program for the study of nursing. This was an independently funded school that came into existence through the Nightingale fund, money provided by the "Tommies" and loved ones of the British soldiers who ~erved in the Crimea. This fund was a way of showing appreciation for Ms. Nightingale's many contributions during the Crimean War. She had a clear understanding of what nursing was and was not, and listed as criteria for entrance into her school that women (no men allowed) had to be over 25 years of age, highly intelligent and committed to life-long practice. She made sure that the curriculum was designed with a holistic approach to patient care and that what the students learned in the classroom they would immediately take to the clinical area and practice. Ms. Nightingale made sure that there was a 1:2 ratio of faculty to students in the clinical area so that safe and scientific learning could take place. She designed her nursing school to produce two levels of nurses. The first level of nursing was for the ordinary probationer, the uneducated but bright young woman who came to her program for one year and then stayed on to practice at St. Thomas Hospital as a nursing sister, under the supervision of the matron of the hospital. The second level of program was for the gentlewoman probationer, who were women like Ms. Nightingale-well educated, politically connected and aware. During her career she wrote 15 books and became an expert on hospital architecture, epidemiology, and nursing. Some of these "gentlewomen," like Ms. Nightinga-le herself, had had extensive private tutoring, so that if we
25
were to measure their educations with our modern-day education system, they would probably be prepared above the level of our present PhD graduates. The gentlewomen probationers also took part in the one-year program along with the ordinary probationers. However, they were required to stay on a second and third year to learn district nursing, what we would call public health nursing, nurse midwifery, and administration and management skills so that they could be sent out to serve as matrons and superintendents of hospitals all over the world. Ms. Nightingale's school produced an elite core of nurses, experts in both the theory and the practice of nursing. In his book Prophets, Priests & Kings, written in 1902, A.G. Gardiner said of Ms. Nightingale, "She was not just the lady with the lamp, she was the lady with the brain, one of those rare personalities who reshapes the contours of life." In 1907, King Edward VII declared she was to receive the Order of Merit for intellectual prowess. Only one woman since that time has received this honor-a physicist-approximately 10 years ago. The Nightingale model of nursing education did not transplant to the United States during the Civil War, despite the fact that Ms. Nightingale wrote to several American physicians, Dorothea Dix and others, with advice regarding war nursing and nursing education. As a resulC between 1868 and 1900, approximately 1,000 schools of nursing were begun throughout the United States without adequate faculty, curriculum, teaching facilities, budget or safe living environments for nursing students. Students were exploited and used as cheap labor. Some felt that only those with strong backs and weak minds were wanted. Both a military mentality and a pseudo-religiosity evolved following the Civil War, so that nursing students and nurses were expected to show obedience, humility and a tendency toward martyrdom. Their reward was to be "pie in the sky by and by/' and those students who were intelligent, brave, assertive and witty not only went unrewarded but rather often found 26
themselves dismissed from school as incorrigibles. It was not until 1919 that the University of Minnesota began the first nursing program with a baccalaureate degree in nursing offered to students who had truly matriculated into the university and met the same requirements applied to other baccalaureate students. Since 1950, masters and doctoral programs have evolved for advanced preparation in nursing, while twoyear AD programs have provided an alternative for basic preparation. Today there is great confusion about nursing education programs.
There are one-year programs for the practical nurse; two-year programs for the associate degree graduate; three-year programs for the graduate of a diploma school; four-year programs that graduate bachelor of science in nursing; five- to six -year programs that include masters preparation; and, of course, longer programs for those seeking the PhD, EdD, DNS, and postdoctoral work. Two-, three- and four-year graduates of nursing programs take the same state boards and end up with the same certification. Today's state boards of nursing still test for sickness knowledge and hospital knowledge. They do not test for the additional rna terials found in curricula of baccalaureate programs, namely, community health, epidemiology and so forth. Nursing has the same problems as pharmacy with state boards, endorsement (reciprocityL nursing assistants, etc.
Academic Nursing Today Academic nursing today is a part of the university with emphasis on teaching, research and practice. Nursing, like pharmacy, feels grea't pressure from taxpayers, students,
parents, alumni, faculty, central administration and local state and federal governments. Most baccalaureate nursing programs are four years, or four years and one summer in length. In the initial part of the program, the student studies the nature of humanity through the liberal arts education. Upon this base is built an understanding of the nature of the profession, emphasizing not only the nursing that focuses on pathology but also one that focuses on health. In most instances today, assessment, teaching and counseling skills are included in the baccalaureate program. A student graduates from the bachelor of science in nursing program as a beginning generalist. It is at the masters level that nursing specialization begins, and many modern programs in masters education provide for both a clinical specialty and a skill in a functional area (such as teaching, administration or research). As a result, graduates from masters programs are often found in key positions in clinical practice, teaching and administration. Although the field still does not have many programs at the doctorallevet the purpose of a doctorate in nursing is to provide expert nurse clinicians and expert nurse investigators. Nursing research problems often include such areas as compliance, obesity, sleep, fatigue, anxiety, skin care, oral hygiene and pain. Nursing also has some nurse scientists, who are PhD nurses known as nurse-anthropologists, nurse-physiologists, nurse-anatomists, nursesociologists, nurse-psychologists and so forth. Other nurses choose PhDs in nonscience fields such as business administration, hospital administration, higher education administration, educational psychology, and economics. Lest it sound as if there are large numbers of doctorally prepared nurses, I should add that there are only about 1,300 nurses with earned doctorates in the United States today. This year in academia it is reported that there are approximately 500 budgeted positions open for nurses with the earned doctorate and approximately 1,100 budgeted posiAmerican Pharmacy Voi.NS18, No.6 , June 1978/306
tions available for nurses with the earned masters. These openings do not count positions available in hospitals, nursing homes, government, Veterans Administration, public health agencies, public schools, industry and so forth. Highly trained personnel is in short supply now, but when the time comes for the United States to have a national health insurance program, not just a nationwide sickness insurance program, it is easy to understand why even more nurses will need to be prepared on the masters and doctoral level to help society fulfill its health maintenance needs.
Present Problems and Challenges We in nursing have problems with titles. We have nurse practitioners, nurse clinicians I, II, III, nurse clinical specialists I, II, III, nursing researchers, nurse scientists, nurse historiographers, school nurses, and public health nurses. It is difficult to define their functions since they are prepared at different levels and in different kinds of programs. Some have had on-the-job training, others have merely attended workshops or short-term courses. Still others have had bachelors, masters and doctoral preparation in their specialties before using these titles. Perhaps it would be easier if we just got back to calling nurses "nurse." We also have entry-of-practice difficulties. At present, entry into practice for the registered nurse can begin at the associate degree level or at the diploma level. However, there is proposed legislation in many states which would restrict the entry into practice as a professional nurse to those with baccalaureate preparation. Nurses with lesser training would be viewed essentially as technicians. Obviously, in the states where this legislation is evolving, there are very heated battles with some people who believe that they are losing prestige. Nursing has "reality shock" problems. A book by Marlene Kramer, nursing faculty member of the University of California at San Francisco, entitled Reality Shock: Why Nurses Leave Nursing, clearly shows that beginners in nursing are often not wanted and not .supported by those American Pharmacy Voi .NS18, No . 6, June 1978/ 307
who are seasoned and practicing in the area. Beginners in many areas of nursing are expected to perform at the level of experienced professionals and are ridiculed when they cannot. Many baccalaureate nurses and masters nurses are thought of as "elitist" or "super-nurses" and therefore receive the wrath of their older colleagues who feel inferior to such better prepared youngsters. Nursing obviously is wrestling to maintain its independent, intraindependent, and interdependent relationships and is continually striving to improve nurse-to-nurse referrals,
'It is not unusual to see pharmacists at a high counter, in the middle of a public place, nestled between sexual apparatus and vitamin pills, trying .t o teach and counsel those seeking help.' nurse-to-physician referrals, nurseto-dentist referrals, nurse-to-social worker referrals, nurse-to-lawyer referrals, and nurse-to-pharmacist referrals. Nursing is walking in the patients' or clients' moccasins in order to help the patient or client cope, learn, accept and work toward high-level health. Nursing is promoting the health of human beings by using a holistic and longitudinal approach. Rozella Schlotfeldt states that nursing must be a scientific, humanistic and learned profession. Pharmacy also has its problems. The literature points out that you too have problems with titles. You have clinical pharmacists, drug therapy specialists, drug delivery specialists, and drug _delivery dispensers. You are presently discussing your entry of practice level: should it be the baccalaureate degree or the PharmD? Several people have spoken on whether or not new pharmacy graduates are prepared to run a pharmacy business. Clearly, you also have a "super-pharmacist" problem relating to the pharmacist who is a scientist. You continue to question your independent role and your interdependentandintradependentrelationships.
Obviously, the pharmacist needs to do more teaching and counseling of patients and customers, even though the architecture of many pharmacies makes this nearly impossible. It is not unusal to see pharmacists at a high counter, in the middle of a public place, nestled between sexual apparatus and vitamin pills, trying to teach and counsel those seeking help. A private place to talk is obviously needed. It is important to note here that the profession of nursing has always valued and still does value and need clinical pharmacists, hospital pharmacists and neighborhood pharmacists. As medications become more complex, as their numbers increase, as patients frequently have multiple physicians and dentists caring for them simultaneously, trying to unravel complex medication problems can only be done by the most knowledgeable person in that area-the pharmacist.
The Future for Academic Pharmacy and Academic Nursing Assuming that (1) we are going to continue to have an increasingly sophisticated society which has higher expectations regarding the right to health; (2) citizens will live longer; (3) the knowledge explosion will continue to increase in both the basic and the social sciences, as well as in the health fields; and (4) more students will be coming into nursing and pharmacy with baccalaureate degrees in other areas, I believe that both academic nursing and academic pharmacy will ultimately have their entry of professional education at the post-baccalaureate level. In nursing I would hope that this post-baccalaureate program would begin with a core of material common to all students. Then, when students know their strengths or weaknesses (these would be highly select students), they could determine whether they wished to obtain the DNS, so that their energies would be used for clinical research, clinical investigations, and practice of an applied nature, or whether they were more theoretically and academically oriented so that they could choose the pathway to a PhD where their research investigations would be of a
27
more basic nature with a theoretical character. Frankly, I believe that the technical programs in nursing, and I am saying the one-, two-, and three-year programs, will ultimately need to become baccalaureate programs so that technical nurses will have the bachelor of science in nursing and professional nurses will have the earned doctorate, whether the PhD or the DNS. Vis-a-vis your own field, you may wish to consider two levels of pharmacists-the more technical type at the baccalaureate level (the dispenser, who is a generalist ) and the specialist, theoretician , academician at the doctoral levet including both the PharmD a nd the PhD, the PharmD providing clinical and applied research investiga tion and th e PhD providing pure research investigation. However, I would be less than candid if I did not let you know that these suggestions of mine in regard to nursing are considered heresy by many of my colleagues. And I am sure that many of your colleagues would feel the same about similar suggestions for the field of pharmacy.
June 8-14
17-18
20-21
20-21
16-18
17-22 23-25
Interpack '7 8,Eighthinterna ~
tiona I fair for packaging machinery and materials, and confectionery machinery, Dusseldorf, West Germany Public Responsibility in Medicine and Research, Second National Symposium, Harvard School of Public Health, Boston, MA The Delaware Pharmaceutical Society's 92nd Annual Convention, Hotel duPont, Wilmington, DE Delaw are Pharmace utic al Socie ty's 92nd Annual Conve nti o n, H otel duPo nt, Wilmington, DE Maryland Society of Hospital Pharmacists, 13th annual hospital pharmacy seminar, The Cascades and Motor House, Williamsburg, VA American Medical Assn. annual meeting, St . Louis, MO Connecticut Pharmaceutical Assn . annual meeting, Berkshires, South Egremont, MA
Conclusion Since it is my belief that pharmacy and nursing have much in common throughout history, in present practice and probably in the future , I would like to finish with the admonition given to academic pharmacy in 1952 (I infer that this is for both colleges of pharmacy and nursing) by W. Paul Briggs. He declared that the following professional needs must be met : • More inspired teachers; • More creative researchers; • Stronger colleges; • More highly modernized curricula; • The strength of professional ideals; • Proper public and professional appreciation; • A clearer understanding of interdependence of all phases of the profession; • A revitalized practice; • A deeper self-respect for our indispensability on the health service team. o 28
July 12-16 Rho Pi Phi International Pharmaceutical Fraternity, 1978 International Convention, Brown 's Hotel, Catskill, NY 16-20 American Assn. of Colleges of Pharmacy annual meeting, Hyatt House, Orlando, FL 27The Fourth North American 29 Symposium on Long-Term Care Administration, sponsored by the American College of Nursing Home Administrators, Del Monte Hyatt House, Monterey, CA
APhAAnnual Meetings April21-26, 1979 Anaheim, CA April19-24, 1980 Washington, DC APhA Academy of Pharmaceutical Sciences National Meetings November 12-16, 1978 The Diplomat, Hollywood, FL November 11-15, 1979 Kansa~ City, MO
August 14-17 American Society of Pharmacognosy and the Phytochemical Society of North America, Oklahoma State University, Stillwater, OK
Continuing Education June 11-14 American Society of Hospital Pharmacists, Institute on Ambulatory Pharmacy Service, H ya tt Regen cy Hotel, Memphis, TN Contact : (301) 65 7-3000 12-16 Ninth Annu al Clinical Pharmacy Program, Division of Extension Services, Albany College of Pharmacy of Union University, Albany, NY Contact: Prof. Albert M . White, Albany College of Pharmacy, 106 New Scotland Ave ., Albany, NY 12202 14-17 American Society of Hospital Pharmacists, Institute on Training and Use of Hospital Pharmacy Technicians, Hyatt Regency Hotel, Memphis, TN Contact: (301) 657-3000 16-30 State University of New York at Buffalo, International Understand ing of the Health Care Delivery System in Scandinavia, Sweden , Finland Contact: SUNY at Buffalo office of Continuing Educa tion, School of Health-Related Professions, 202 Foster Hall, Buffalo NY 14214 July 16-19 American Society of Hospital Pharmacists, Institute on Computers and Pharmacy, Las Vegas, NV Contact: (301) 657-3000 19-22 American Society of Hospital Pharmacists, Institute on Pharmacy Computer Systems, Las Vegas, NV Contact: (301) 657-3000 3118th Annual Conference on Aug. 4 Pharmaceutical Analysis; sponsored by University of Wisconsin-Extension, Dell View Hotel, Lake Delton, WI Contact: (608) 262-3130 August 13-16 American Society of Hospital Pharmacists, postgraduate education course, Pittsburgh Hyatt House, Pittsburgh, PA Contact: (301) 657-3000
American Pharmacy Voi.NS18 , No.6, June 1978/ 308
I
had a difficult time deciding on a title for this pres entation. There were other titles I considered, such as "Doctors are not the only doctors in health care," or "Everything I've always wan ted to know about colleges of pharmacy but was afraid to ask." At one paint, I decided the topic should be "Misery loves company," but then I decided the best title was "But some of my best friends are pharmacists." I plan to approach the topic first giving historical overviews of pharmacy and nursing. From there, I will look at academic pharmacy and nursing as they exist today, will consider many of our present
Evelyn R. Barritt, RN, PhD, is Dean and professor of Nursing at the College of Nursing, University of Iowa, Iowa City, Iowa 52242. This article is based on Dr. Barritt's presentation to the Council of Deans, American Association of Colleges of Pharmacy, on March 1, 1978, in Kansas City, Missouri. The meeting, an open hearing, focused on the types of pharmacy personnel required to meet society's future needs and included ample discussion of the "one degree controversy" (BS in pharmacy and/or doctor of pharmacy). It is expected that the AACP will make a final recommendation on that controversy at its annual meeting july 16-20, 1978, in Orlando, Florida. For copies of Dr. Barritt's references and resources, contact the editor of American Ph arm
problems, and will close by predicting the future for both academic pharmacy and academic nursing.
Historical Overview of Pharmacy For the pre-Judea-Christian era, there are few written records to consult on the practice of pharmacy. Myths and folklore provide . some evidence of the fact that there was plant gathering for use in the medication and treatment of animals and human beings, but there is no evidence of there being a science of pharmacy. The Wellcome Medical Museum in London portrays pharmacy as an advanced art in ancient Arabia, but there is no evidence of pharmacy being considered a science with systematic investigation of outcomes. From the sixth to fourteenth centuries in Europe, pharmacy appears to have been a part of medicine, not a separate entity. In 1240 Emperor Frederick II issued the edict, your Magna Charta of Pharmacy, that (1) there would be a separation of the pharmaceutical profession from the medical profession, (2) there would be official supervision of the practice of pharmacy, (3) there would be a limited number of pharmacies, and (4) prices would be fixed as would the use of a prescribed formulary. In the fourteenth century in Europe, pharmacists began to be
+ 24
called apothecaries. By 1618 in London, to be a pharmacist one had to have a seven-year apprenticeship. In 1770 the Spanish governor of Louisiana again separated medicine from pharmacy, declaring that there were three separate professionsmedicine, surgery and pharmacy. In 1821 in Philadelphia, the Philadelphia College of Pharmacy was begun; it was not a college in our sense at all, but merely a trade school. The history of pharmacy in the Civil War period is interesting in that at Baldwin University in 1865, pharmaceu-· tical instruction was begun as a part of general education. In 1868 the University of Michigan began the first full course of study in pharmacy, and in 1883 the University of Wisconsin began the first four-year program. In 1902 the first PhD program in pharmacy was begun, also at the University of Wisconsin. In the meantime, various groups and individuals in pharmacy conducted many
'·-A .
American Pharmacy Voi .NS18, No . 6, June 1978/ 304
surveys and studies asking questions such as the who, when, where, why and why not of academic pharmacy. Control of preparation for professional status was a problem area. Programs in pharmacy during the post-Civil War years and on in to the early 1900s ranged from threemonth programs to one-, two-, three-, four-, five-, and six-year programs. One could choose from among correspondence schools, cramming schools, and "diploma mills." (For $100 you could even receive a doctor of pharmacy degree that did not show that it came from a printing company.) Many pharmacists merely received on-the-job training as drug clerks, later calling themselves pharmacists, or as their customers called them, "doc." The history of academic pharmacy in America shows a wide assortment of other problems as well: state boards; reciprocity (endorsement); the use of pharmacy ass is tan ts, associates, and technicians; pharmacy practice; curriculum (both undergraduate and graduate); student selection; funding; physical plant; clinical issues; continuing education; a sense of mission; internship; research; and problems with those in the ranks holding anti-intellectual and antischolar ideas . Pharmacy and nursing could be viewed as the "Bobbsey Twins" of the academic world. According to the literature, nursing perhaps has more sexist problems along with some medical chauvinism problems, though phar-
macy seems to have felt a certain amount of medical chauvinism also.
Historical Overview of Nursing Turning again to pre-Judea-Christian culture, which seems to have been a matriarchal society, we find no written records of the history of nursing or of health practices. We have the linguistic remnant, however, of a class of feminine-gender words that evolved from the culture, such as faith, hope, mercy, intellect, rectitude, spirit, soul, freedom, charity and joy, which signify nurturant activities. Nurturing is what the profession of nursing is all about. There is a dearth of knowledge of nursing history in such places as Africa, Asia, and Central and South America, and so our · knowledge of our own professional history is decidedly limited to the Judea-Christian era in Europe and surrounding nations. It has long been my belief that many minorities, in particular women, blacks and nurses, have not valued their histories and have not produced their share of historiographers who would help to understand and value the past. As is often pointed out, those who do not know their history are bound to make the same mistakes in the future. Be that as it may, generally speaking, the history of nursing shows two widely divergent roots for its practice, one form of nursing coming from the Christian nuns and monks and another form coming from camp followers, prostitutes and derelicts. With tongue in cheek, one could probably state that one group specialized in the bodies and the other group specialized in the souls.
The Nightingale Influence It was not until the 1860s at St.
American Pharmacy Vo i. NS18 , No . 6 , Jun e 1978/ 305
Thomas Hospital in London that Florence Nightingale devised a systematic and scientific program for the study of nursing. This was an independently funded school that came into existence through the Nightingale fund, money provided by the "Tommies" and loved ones of the British soldiers who ~erved in the Crimea. This fund was a way of showing appreciation for Ms. Nightingale's many contributions during the Crimean War. She had a clear understanding of what nursing was and was not, and listed as criteria for entrance into her school that women (no men allowed) had to be over 25 years of age, highly intelligent and committed to life-long practice. She made sure that the curriculum was designed with a holistic approach to patient care and that what the students learned in the classroom they would immediately take to the clinical area and practice. Ms. Nightingale made sure that there was a 1:2 ratio of faculty to students in the clinical area so that safe and scientific learning could take place. She designed her nursing school to produce two levels of nurses. The first level of nursing was for the ordinary probationer, the uneducated but bright young woman who came to her program for one year and then stayed on to practice at St. Thomas Hospital as a nursing sister, under the supervision of the matron of the hospital. The second level of program was for the gentlewoman probationer, who were women like Ms. Nightingale-well educated, politically connected and aware. During her career she wrote 15 books and became an expert on hospital architecture, epidemiology, and nursing. Some of these "gentlewomen," like Ms. Nightinga-le herself, had had extensive private tutoring, so that if we
25
were to measure their educations with our modern-day education system, they would probably be prepared above the level of our present PhD graduates. The gentlewomen probationers also took part in the one-year program along with the ordinary probationers. However, they were required to stay on a second and third year to learn district nursing, what we would call public health nursing, nurse midwifery, and administration and management skills so that they could be sent out to serve as matrons and superintendents of hospitals all over the world. Ms. Nightingale's school produced an elite core of nurses, experts in both the theory and the practice of nursing. In his book Prophets, Priests & Kings, written in 1902, A.G. Gardiner said of Ms. Nightingale, "She was not just the lady with the lamp, she was the lady with the brain, one of those rare personalities who reshapes the contours of life." In 1907, King Edward VII declared she was to receive the Order of Merit for intellectual prowess. Only one woman since that time has received this honor-a physicist-approximately 10 years ago. The Nightingale model of nursing education did not transplant to the United States during the Civil War, despite the fact that Ms. Nightingale wrote to several American physicians, Dorothea Dix and others, with advice regarding war nursing and nursing education. As a resulC between 1868 and 1900, approximately 1,000 schools of nursing were begun throughout the United States without adequate faculty, curriculum, teaching facilities, budget or safe living environments for nursing students. Students were exploited and used as cheap labor. Some felt that only those with strong backs and weak minds were wanted. Both a military mentality and a pseudo-religiosity evolved following the Civil War, so that nursing students and nurses were expected to show obedience, humility and a tendency toward martyrdom. Their reward was to be "pie in the sky by and by/' and those students who were intelligent, brave, assertive and witty not only went unrewarded but rather often found 26
themselves dismissed from school as incorrigibles. It was not until 1919 that the University of Minnesota began the first nursing program with a baccalaureate degree in nursing offered to students who had truly matriculated into the university and met the same requirements applied to other baccalaureate students. Since 1950, masters and doctoral programs have evolved for advanced preparation in nursing, while twoyear AD programs have provided an alternative for basic preparation. Today there is great confusion about nursing education programs.
There are one-year programs for the practical nurse; two-year programs for the associate degree graduate; three-year programs for the graduate of a diploma school; four-year programs that graduate bachelor of science in nursing; five- to six -year programs that include masters preparation; and, of course, longer programs for those seeking the PhD, EdD, DNS, and postdoctoral work. Two-, three- and four-year graduates of nursing programs take the same state boards and end up with the same certification. Today's state boards of nursing still test for sickness knowledge and hospital knowledge. They do not test for the additional rna terials found in curricula of baccalaureate programs, namely, community health, epidemiology and so forth. Nursing has the same problems as pharmacy with state boards, endorsement (reciprocityL nursing assistants, etc.
Academic Nursing Today Academic nursing today is a part of the university with emphasis on teaching, research and practice. Nursing, like pharmacy, feels grea't pressure from taxpayers, students,
parents, alumni, faculty, central administration and local state and federal governments. Most baccalaureate nursing programs are four years, or four years and one summer in length. In the initial part of the program, the student studies the nature of humanity through the liberal arts education. Upon this base is built an understanding of the nature of the profession, emphasizing not only the nursing that focuses on pathology but also one that focuses on health. In most instances today, assessment, teaching and counseling skills are included in the baccalaureate program. A student graduates from the bachelor of science in nursing program as a beginning generalist. It is at the masters level that nursing specialization begins, and many modern programs in masters education provide for both a clinical specialty and a skill in a functional area (such as teaching, administration or research). As a result, graduates from masters programs are often found in key positions in clinical practice, teaching and administration. Although the field still does not have many programs at the doctorallevet the purpose of a doctorate in nursing is to provide expert nurse clinicians and expert nurse investigators. Nursing research problems often include such areas as compliance, obesity, sleep, fatigue, anxiety, skin care, oral hygiene and pain. Nursing also has some nurse scientists, who are PhD nurses known as nurse-anthropologists, nurse-physiologists, nurse-anatomists, nursesociologists, nurse-psychologists and so forth. Other nurses choose PhDs in nonscience fields such as business administration, hospital administration, higher education administration, educational psychology, and economics. Lest it sound as if there are large numbers of doctorally prepared nurses, I should add that there are only about 1,300 nurses with earned doctorates in the United States today. This year in academia it is reported that there are approximately 500 budgeted positions open for nurses with the earned doctorate and approximately 1,100 budgeted posiAmerican Pharmacy Voi.NS18, No.6 , June 1978/306
tions available for nurses with the earned masters. These openings do not count positions available in hospitals, nursing homes, government, Veterans Administration, public health agencies, public schools, industry and so forth. Highly trained personnel is in short supply now, but when the time comes for the United States to have a national health insurance program, not just a nationwide sickness insurance program, it is easy to understand why even more nurses will need to be prepared on the masters and doctoral level to help society fulfill its health maintenance needs.
Present Problems and Challenges We in nursing have problems with titles. We have nurse practitioners, nurse clinicians I, II, III, nurse clinical specialists I, II, III, nursing researchers, nurse scientists, nurse historiographers, school nurses, and public health nurses. It is difficult to define their functions since they are prepared at different levels and in different kinds of programs. Some have had on-the-job training, others have merely attended workshops or short-term courses. Still others have had bachelors, masters and doctoral preparation in their specialties before using these titles. Perhaps it would be easier if we just got back to calling nurses "nurse." We also have entry-of-practice difficulties. At present, entry into practice for the registered nurse can begin at the associate degree level or at the diploma level. However, there is proposed legislation in many states which would restrict the entry into practice as a professional nurse to those with baccalaureate preparation. Nurses with lesser training would be viewed essentially as technicians. Obviously, in the states where this legislation is evolving, there are very heated battles with some people who believe that they are losing prestige. Nursing has "reality shock" problems. A book by Marlene Kramer, nursing faculty member of the University of California at San Francisco, entitled Reality Shock: Why Nurses Leave Nursing, clearly shows that beginners in nursing are often not wanted and not .supported by those American Pharmacy Voi .NS18, No . 6, June 1978/ 307
who are seasoned and practicing in the area. Beginners in many areas of nursing are expected to perform at the level of experienced professionals and are ridiculed when they cannot. Many baccalaureate nurses and masters nurses are thought of as "elitist" or "super-nurses" and therefore receive the wrath of their older colleagues who feel inferior to such better prepared youngsters. Nursing obviously is wrestling to maintain its independent, intraindependent, and interdependent relationships and is continually striving to improve nurse-to-nurse referrals,
'It is not unusual to see pharmacists at a high counter, in the middle of a public place, nestled between sexual apparatus and vitamin pills, trying .t o teach and counsel those seeking help.' nurse-to-physician referrals, nurseto-dentist referrals, nurse-to-social worker referrals, nurse-to-lawyer referrals, and nurse-to-pharmacist referrals. Nursing is walking in the patients' or clients' moccasins in order to help the patient or client cope, learn, accept and work toward high-level health. Nursing is promoting the health of human beings by using a holistic and longitudinal approach. Rozella Schlotfeldt states that nursing must be a scientific, humanistic and learned profession. Pharmacy also has its problems. The literature points out that you too have problems with titles. You have clinical pharmacists, drug therapy specialists, drug delivery specialists, and drug _delivery dispensers. You are presently discussing your entry of practice level: should it be the baccalaureate degree or the PharmD? Several people have spoken on whether or not new pharmacy graduates are prepared to run a pharmacy business. Clearly, you also have a "super-pharmacist" problem relating to the pharmacist who is a scientist. You continue to question your independent role and your interdependentandintradependentrelationships.
Obviously, the pharmacist needs to do more teaching and counseling of patients and customers, even though the architecture of many pharmacies makes this nearly impossible. It is not unusal to see pharmacists at a high counter, in the middle of a public place, nestled between sexual apparatus and vitamin pills, trying to teach and counsel those seeking help. A private place to talk is obviously needed. It is important to note here that the profession of nursing has always valued and still does value and need clinical pharmacists, hospital pharmacists and neighborhood pharmacists. As medications become more complex, as their numbers increase, as patients frequently have multiple physicians and dentists caring for them simultaneously, trying to unravel complex medication problems can only be done by the most knowledgeable person in that area-the pharmacist.
The Future for Academic Pharmacy and Academic Nursing Assuming that (1) we are going to continue to have an increasingly sophisticated society which has higher expectations regarding the right to health; (2) citizens will live longer; (3) the knowledge explosion will continue to increase in both the basic and the social sciences, as well as in the health fields; and (4) more students will be coming into nursing and pharmacy with baccalaureate degrees in other areas, I believe that both academic nursing and academic pharmacy will ultimately have their entry of professional education at the post-baccalaureate level. In nursing I would hope that this post-baccalaureate program would begin with a core of material common to all students. Then, when students know their strengths or weaknesses (these would be highly select students), they could determine whether they wished to obtain the DNS, so that their energies would be used for clinical research, clinical investigations, and practice of an applied nature, or whether they were more theoretically and academically oriented so that they could choose the pathway to a PhD where their research investigations would be of a
27
more basic nature with a theoretical character. Frankly, I believe that the technical programs in nursing, and I am saying the one-, two-, and three-year programs, will ultimately need to become baccalaureate programs so that technical nurses will have the bachelor of science in nursing and professional nurses will have the earned doctorate, whether the PhD or the DNS. Vis-a-vis your own field, you may wish to consider two levels of pharmacists-the more technical type at the baccalaureate level (the dispenser, who is a generalist ) and the specialist, theoretician , academician at the doctoral levet including both the PharmD a nd the PhD, the PharmD providing clinical and applied research investiga tion and th e PhD providing pure research investigation. However, I would be less than candid if I did not let you know that these suggestions of mine in regard to nursing are considered heresy by many of my colleagues. And I am sure that many of your colleagues would feel the same about similar suggestions for the field of pharmacy.
June 8-14
17-18
20-21
20-21
16-18
17-22 23-25
Interpack '7 8,Eighthinterna ~
tiona I fair for packaging machinery and materials, and confectionery machinery, Dusseldorf, West Germany Public Responsibility in Medicine and Research, Second National Symposium, Harvard School of Public Health, Boston, MA The Delaware Pharmaceutical Society's 92nd Annual Convention, Hotel duPont, Wilmington, DE Delaw are Pharmace utic al Socie ty's 92nd Annual Conve nti o n, H otel duPo nt, Wilmington, DE Maryland Society of Hospital Pharmacists, 13th annual hospital pharmacy seminar, The Cascades and Motor House, Williamsburg, VA American Medical Assn. annual meeting, St . Louis, MO Connecticut Pharmaceutical Assn . annual meeting, Berkshires, South Egremont, MA
Conclusion Since it is my belief that pharmacy and nursing have much in common throughout history, in present practice and probably in the future , I would like to finish with the admonition given to academic pharmacy in 1952 (I infer that this is for both colleges of pharmacy and nursing) by W. Paul Briggs. He declared that the following professional needs must be met : • More inspired teachers; • More creative researchers; • Stronger colleges; • More highly modernized curricula; • The strength of professional ideals; • Proper public and professional appreciation; • A clearer understanding of interdependence of all phases of the profession; • A revitalized practice; • A deeper self-respect for our indispensability on the health service team. o 28
July 12-16 Rho Pi Phi International Pharmaceutical Fraternity, 1978 International Convention, Brown 's Hotel, Catskill, NY 16-20 American Assn. of Colleges of Pharmacy annual meeting, Hyatt House, Orlando, FL 27The Fourth North American 29 Symposium on Long-Term Care Administration, sponsored by the American College of Nursing Home Administrators, Del Monte Hyatt House, Monterey, CA
APhAAnnual Meetings April21-26, 1979 Anaheim, CA April19-24, 1980 Washington, DC APhA Academy of Pharmaceutical Sciences National Meetings November 12-16, 1978 The Diplomat, Hollywood, FL November 11-15, 1979 Kansa~ City, MO
August 14-17 American Society of Pharmacognosy and the Phytochemical Society of North America, Oklahoma State University, Stillwater, OK
Continuing Education June 11-14 American Society of Hospital Pharmacists, Institute on Ambulatory Pharmacy Service, H ya tt Regen cy Hotel, Memphis, TN Contact : (301) 65 7-3000 12-16 Ninth Annu al Clinical Pharmacy Program, Division of Extension Services, Albany College of Pharmacy of Union University, Albany, NY Contact: Prof. Albert M . White, Albany College of Pharmacy, 106 New Scotland Ave ., Albany, NY 12202 14-17 American Society of Hospital Pharmacists, Institute on Training and Use of Hospital Pharmacy Technicians, Hyatt Regency Hotel, Memphis, TN Contact: (301) 657-3000 16-30 State University of New York at Buffalo, International Understand ing of the Health Care Delivery System in Scandinavia, Sweden , Finland Contact: SUNY at Buffalo office of Continuing Educa tion, School of Health-Related Professions, 202 Foster Hall, Buffalo NY 14214 July 16-19 American Society of Hospital Pharmacists, Institute on Computers and Pharmacy, Las Vegas, NV Contact: (301) 657-3000 19-22 American Society of Hospital Pharmacists, Institute on Pharmacy Computer Systems, Las Vegas, NV Contact: (301) 657-3000 3118th Annual Conference on Aug. 4 Pharmaceutical Analysis; sponsored by University of Wisconsin-Extension, Dell View Hotel, Lake Delton, WI Contact: (608) 262-3130 August 13-16 American Society of Hospital Pharmacists, postgraduate education course, Pittsburgh Hyatt House, Pittsburgh, PA Contact: (301) 657-3000
American Pharmacy Voi.NS18 , No.6, June 1978/ 308
