Journal of Advanced Nursing, 1976, I, 429-433
Summary report of a symposium on higher education in nursing World Health Organization The Hague, 30 October-j
November
Since this summary report first appeared, a number of innovations in higher education in nursing have taken place in Europe at basic, post-basic, undergraduate and postgraduate levels. Whether or not this kind of education for nurses can be argued to be 'Learning for Reality' {Bendall 1976) will no doubt be a topic of fascination for future researchers. Nevertheless, participants at the symposium believed that it would lead to many benefits to health services delivery.
Introduction In 1972, the Regional Office for Europe of the World Health Organization in collaboration with the govemment of the Netherlands convened a symposium to discuss higher education in nursing. This multidisciplinary meeting was held in The Hague and was attended by 29 participants from 21 countries, 10 temporary advisers, 2 representatives from non-governmental organizations, 4 observers and 4 members of the staff of WHO. Dr W. B. Gerritsen, Director-General of Public Health, opened the meeting on behalf of his government, and Dr Leo A. Kaprio, Regional Director, addressed the gathering on behalf of WHO. The purpose of the symposium was to explore ways in which the resources of universities and higher education might be used to develop the nursing leadership essential to modern health services delivery. In order that all persons attending the symposium might direct their thinking and discussion to the precise theme ofthe meeting, certain definitions and assumptions were developed as starting points for reasoning. Among the more important of these were the following: 1 In many countries all personnel providing nursing services are known as nurses. The symposium defmed 'the nurse' around whom the discussions were to centre as the worker in any country at the 'top' of the nursing personnel system. To paraphrase the words of the Fifth Report of the WHO Expert Committee on Nursing (World Health Organization 1966) this worker provides the most skilled nursing care in the hospital or community and makes independent decisions based on scientific, clinical and management principles. 2 Nurses are providers of health services and should be able to work interdependently with physicians, social workers, physical therapists and others to help people achieve, maintain and regain health. 429
430
World Health Organization
3 Nurses function in all areas, both within and outside institutions and other centres where health services are provided. The nursing function has been expanding and is in continuous evolution in all areas of health care. This function includes the provision of highly skilled nursing care, teaching, administration and research. 4 Students of nursing have the same right as aU other individuals to be educated in the highest educational institution in a country. 5 Health care impUes not only the care of the acutely and chronically ill, but also rehabilitation, health education, health maintenance, prevention of disease and disability and early case-finding. The provision of health services involves the synthesis or integration of the skills of many professions. Health personnel in cooperation with clients, families and communities, work towards the achievement of health care goals. 6 Health care is a basic human right.
The changing role of nursmg in the delivery of health services As previously stated nursing care in most countries is delivered by a variety of workers who provide services which range from simple repetitive manual skills based on predetermined patterns of response to services involving a high level of judgement in applying scientific principles and in choosing the appropriate action to be taken. Therefore, the nursing personnel system through which these services reach the public usually consists of two or three levels of workers. The range of services which can and should be provided through this flexible system is constantly undergoing change. The role of the worker at the highest level of this system—'the nurse'—^is at present in a very active phase of both redefinition and expansion. The work of the 'nurse' reflects changes which are taking place in health services as a whole. These changes demonstrate: 1 The increased interdependence of aU health disciplines; 2 The increased need for including the expertise of all health professions, especially nursing, in the decision-making process of care; 3 The need to identify more economic and more effective systems for the delivery of health care; 4 The need to develop a flexible health career system which will enable all categories of health workers to realize their fullest potential. The increasing importance of continuing care and supervision of patients on discharge from hospitals, the development of technology in the care of groups at high risk, the need for more and better health education ofthe public, the increasing demand for better and more economic primary health care and the availability of increasing numbers of young men and women who have completed secondary education—all are exerting influences on the role of nursing in the dehvery of health services.
The education of 'the nurse' The predominant nursing education pattem in most countries is the hospitalbased model. This model is the one most commonly employed to educate all levels
Symposium on higher education in nursing
431
of workers within the nursing personnel system regardless of their function in the service situation. These educational programmes are essentially Ulness-oriented and consequently poorly adapted to prepare workers to provide nursing services in all aspects of health care. Further, these programmes prepare nursing personnel in isolation from all other health and related professions. The preparation of 'the nurse' in these settings is tradition-bound and in many instances has httle relevance to the present or the future. Inherent in this educational pattern is the provision of nursing and hospital services by the student. While learning in a reahty situation is essential for all professions which care for people, the dependence on student nurses for the provision of 60-80% of nursing services in hospitals, as documented by research in several countries represented at the symposium, can only underline the illusory nature ofthe leaming value of such experience. Under these circumstances leaming becomes centred on the procedural and routine aspects of care. Furthermore, the pressure on students to meet such a high proportion of the service needs in hospitals may be one factor in the dehumanization of such services. The members ofthe symposium were in agreement that 'the nurse' as defined by the symposium should be educated in universities or equivalent institutions of higher education. Since 'the nurse' is expected 'to provide the most skilled nursing care in the hospital or community service', to undertake leadership functions within the nursing team, and to work on a partnership basis with the doctor and other professional-level health workers, it would seem obvious that it is necessary for her to be prepared in the educational setting which best would allow her to acquire the knowledge and develop the skills and attitudes essential to fulfilling these functions. The rich resources of the university are needed to prepare the student-nurse for adapting to change and to the unknown, for developing a desire for lifelong leaming, for acquiring the habits of analytical thinking and investigation which are basic to the nursing process, and for acquiring a sound scientific basis for the practice of nursing. Human relations and communication skills can be more readily developed in an educational environment which, by its very nature and tradition, brings all disciplines together and provides access to a wealth of reference and other leaming materials. Further, the development ofa nursing science, from which unifying principles essential to guide nursing practice can be derived, can only evolve within the university of which research is an inherent part. Nursing can develop as an apphed science only when its members have the opportunity to base their knowledge on depth studies of the physical, biological and the behavioural sciences, i.e. when student nurses in each society have access to institutions of higher education together with medical and other professional students.
Nursing within the university or institute of higher leaming Universities, which by tradition are dedicated to the preservation of the culture and to fundamental research, are, hke other social institutions, undergoing reform and change. The most discernible trends are in the direction of greater concem
432
World Health Organization
and involvement with social needs and in the development of human talent to meet such needs. The education of 'the most skilled worker' in the majority of health professions has now found its way into the university. Why has nursing failed to do so and why should it be necessary to continually seek for justification for this move ? Unfortunately, in many instances, even the development of advanced educational programmes for nurses has not led to the university. While post-basic courses have been widely established throughout the European region, relatively few are integrated into or affiliated with universities or institutes of higher education. In many countries outside the region the incorporation of these programmes into the university has been a first step leading to the development of universitybased education for 'the nurse'. Once basic education has been established in the university, post-basic courses have been phased out, and it has then been possible to estabhsh postgraduate studies which could provide truly advanced learning and which need not concentrate on remedying deficiencies in the basic education of the student. In a few countries in the region, the doors of the universities have already been opened to students wishing to study nursing. In these settings it has been demonstrated that student nurses not only take from the university but bring to it a motivation and perspective which enrich the learning milieu. The funding of academic education for nurses, where such programmes already exist in the region, is done through a vsdde network of sources. These range from government financing through ministries of education and ministries of health separately or in collaboration, to such other sources as private, national or intemational foundations and professional organizations. Constraints to financing of academic/higher education for nursing were considered to be largely administrative and practical in nature and not insurmountable. In fact, the symposium expressed its belief that student nurses are no different from other students in fitting into the general education system of a country. Where opportunity to study nursing within the system of higher education ofa country is lacking, students choose another profession within higher education and their education is paid for by govemment anyway. The movement of education for nurses into higher education would benefit the health services delivery in a country in many ways. Such benefits can be summarized as: feedback into health services in quahty of nursing care; increased motivation for young men and women to choose nursing as a career; increased job satisfaction; increased career hfe in nursing; the potential reduction of hospital utihzation when highly skilled nursing care is provided in the primary care system ofa country; greater potential for adaptabihty of health services to change; an increase in the quahty and contribution of nursing to the development of other health manpower for the health services delivery system; and a reduction in the waste of human and financial resources currently concentrated in post-basic nursing education programmes and devoted largely to filling gaps in traditional basic nursing education.
Symposium on higher education in nursing
433
The symposium discussed at some length the planning of change and strategies for bringing about needed changes in education for 'nurses'. Such strategies are discussed in detail in the final report ofthe symposium (World Health Organization 1973). Among the more important of the suggestions put forward by the symposium were the following: 1 Education for nursing should be provided in the general education system of the country and students of nursing should have the same rights and responsibihties as all other students in the educational system. 2 Young people seeking to become 'nurses' should meet the scholastic requirements for entrance into universities, colleges, academies and/or institutions affiHated with universities. 3 In countries where university education for nurses is not already the estabhshed pattem, plans should be made to move this education into universities, colleges, academies and/or institutions affihated with universities. 4 Universities which already provide equivalency examinations for mature students with work experience but lacking full admission requirements, should be encouraged by the health authorities to extend the same privileges to mature, experienced nurses seeking admission to universities. 5 It would be advantageous to the nutsing profession to explore the possibihties offered by different universities for the education of professors of nursing. This should include the education of nurse researchers andof nurse administrators with an interest in teaching in the chnical fields, who then would be quahfied to hold a dual appointment in the hospital and the university.
References BENDALL E . (1976) Learning for reality. Jowrna/ of Advanced Nursing i, 3-9. WORLD HEALTH ORGANIZATION (1966) World Health Organization Technical Report Ser., 347, 13. WORLD HEALTH ORGANIZATION, REGIONAL OFHCE FOR EUROPE (1973) Higher Education in Nursing,
Report on a Symposium, The Hague, 1972, Copenhagen.
Summary report of a symposium on higher education in nursing World Health Organization The Hague, 30 October-j
November
Since this summary report first appeared, a number of innovations in higher education in nursing have taken place in Europe at basic, post-basic, undergraduate and postgraduate levels. Whether or not this kind of education for nurses can be argued to be 'Learning for Reality' {Bendall 1976) will no doubt be a topic of fascination for future researchers. Nevertheless, participants at the symposium believed that it would lead to many benefits to health services delivery.
Introduction In 1972, the Regional Office for Europe of the World Health Organization in collaboration with the govemment of the Netherlands convened a symposium to discuss higher education in nursing. This multidisciplinary meeting was held in The Hague and was attended by 29 participants from 21 countries, 10 temporary advisers, 2 representatives from non-governmental organizations, 4 observers and 4 members of the staff of WHO. Dr W. B. Gerritsen, Director-General of Public Health, opened the meeting on behalf of his government, and Dr Leo A. Kaprio, Regional Director, addressed the gathering on behalf of WHO. The purpose of the symposium was to explore ways in which the resources of universities and higher education might be used to develop the nursing leadership essential to modern health services delivery. In order that all persons attending the symposium might direct their thinking and discussion to the precise theme ofthe meeting, certain definitions and assumptions were developed as starting points for reasoning. Among the more important of these were the following: 1 In many countries all personnel providing nursing services are known as nurses. The symposium defmed 'the nurse' around whom the discussions were to centre as the worker in any country at the 'top' of the nursing personnel system. To paraphrase the words of the Fifth Report of the WHO Expert Committee on Nursing (World Health Organization 1966) this worker provides the most skilled nursing care in the hospital or community and makes independent decisions based on scientific, clinical and management principles. 2 Nurses are providers of health services and should be able to work interdependently with physicians, social workers, physical therapists and others to help people achieve, maintain and regain health. 429
430
World Health Organization
3 Nurses function in all areas, both within and outside institutions and other centres where health services are provided. The nursing function has been expanding and is in continuous evolution in all areas of health care. This function includes the provision of highly skilled nursing care, teaching, administration and research. 4 Students of nursing have the same right as aU other individuals to be educated in the highest educational institution in a country. 5 Health care impUes not only the care of the acutely and chronically ill, but also rehabilitation, health education, health maintenance, prevention of disease and disability and early case-finding. The provision of health services involves the synthesis or integration of the skills of many professions. Health personnel in cooperation with clients, families and communities, work towards the achievement of health care goals. 6 Health care is a basic human right.
The changing role of nursmg in the delivery of health services As previously stated nursing care in most countries is delivered by a variety of workers who provide services which range from simple repetitive manual skills based on predetermined patterns of response to services involving a high level of judgement in applying scientific principles and in choosing the appropriate action to be taken. Therefore, the nursing personnel system through which these services reach the public usually consists of two or three levels of workers. The range of services which can and should be provided through this flexible system is constantly undergoing change. The role of the worker at the highest level of this system—'the nurse'—^is at present in a very active phase of both redefinition and expansion. The work of the 'nurse' reflects changes which are taking place in health services as a whole. These changes demonstrate: 1 The increased interdependence of aU health disciplines; 2 The increased need for including the expertise of all health professions, especially nursing, in the decision-making process of care; 3 The need to identify more economic and more effective systems for the delivery of health care; 4 The need to develop a flexible health career system which will enable all categories of health workers to realize their fullest potential. The increasing importance of continuing care and supervision of patients on discharge from hospitals, the development of technology in the care of groups at high risk, the need for more and better health education ofthe public, the increasing demand for better and more economic primary health care and the availability of increasing numbers of young men and women who have completed secondary education—all are exerting influences on the role of nursing in the dehvery of health services.
The education of 'the nurse' The predominant nursing education pattem in most countries is the hospitalbased model. This model is the one most commonly employed to educate all levels
Symposium on higher education in nursing
431
of workers within the nursing personnel system regardless of their function in the service situation. These educational programmes are essentially Ulness-oriented and consequently poorly adapted to prepare workers to provide nursing services in all aspects of health care. Further, these programmes prepare nursing personnel in isolation from all other health and related professions. The preparation of 'the nurse' in these settings is tradition-bound and in many instances has httle relevance to the present or the future. Inherent in this educational pattern is the provision of nursing and hospital services by the student. While learning in a reahty situation is essential for all professions which care for people, the dependence on student nurses for the provision of 60-80% of nursing services in hospitals, as documented by research in several countries represented at the symposium, can only underline the illusory nature ofthe leaming value of such experience. Under these circumstances leaming becomes centred on the procedural and routine aspects of care. Furthermore, the pressure on students to meet such a high proportion of the service needs in hospitals may be one factor in the dehumanization of such services. The members ofthe symposium were in agreement that 'the nurse' as defined by the symposium should be educated in universities or equivalent institutions of higher education. Since 'the nurse' is expected 'to provide the most skilled nursing care in the hospital or community service', to undertake leadership functions within the nursing team, and to work on a partnership basis with the doctor and other professional-level health workers, it would seem obvious that it is necessary for her to be prepared in the educational setting which best would allow her to acquire the knowledge and develop the skills and attitudes essential to fulfilling these functions. The rich resources of the university are needed to prepare the student-nurse for adapting to change and to the unknown, for developing a desire for lifelong leaming, for acquiring the habits of analytical thinking and investigation which are basic to the nursing process, and for acquiring a sound scientific basis for the practice of nursing. Human relations and communication skills can be more readily developed in an educational environment which, by its very nature and tradition, brings all disciplines together and provides access to a wealth of reference and other leaming materials. Further, the development ofa nursing science, from which unifying principles essential to guide nursing practice can be derived, can only evolve within the university of which research is an inherent part. Nursing can develop as an apphed science only when its members have the opportunity to base their knowledge on depth studies of the physical, biological and the behavioural sciences, i.e. when student nurses in each society have access to institutions of higher education together with medical and other professional students.
Nursing within the university or institute of higher leaming Universities, which by tradition are dedicated to the preservation of the culture and to fundamental research, are, hke other social institutions, undergoing reform and change. The most discernible trends are in the direction of greater concem
432
World Health Organization
and involvement with social needs and in the development of human talent to meet such needs. The education of 'the most skilled worker' in the majority of health professions has now found its way into the university. Why has nursing failed to do so and why should it be necessary to continually seek for justification for this move ? Unfortunately, in many instances, even the development of advanced educational programmes for nurses has not led to the university. While post-basic courses have been widely established throughout the European region, relatively few are integrated into or affiliated with universities or institutes of higher education. In many countries outside the region the incorporation of these programmes into the university has been a first step leading to the development of universitybased education for 'the nurse'. Once basic education has been established in the university, post-basic courses have been phased out, and it has then been possible to estabhsh postgraduate studies which could provide truly advanced learning and which need not concentrate on remedying deficiencies in the basic education of the student. In a few countries in the region, the doors of the universities have already been opened to students wishing to study nursing. In these settings it has been demonstrated that student nurses not only take from the university but bring to it a motivation and perspective which enrich the learning milieu. The funding of academic education for nurses, where such programmes already exist in the region, is done through a vsdde network of sources. These range from government financing through ministries of education and ministries of health separately or in collaboration, to such other sources as private, national or intemational foundations and professional organizations. Constraints to financing of academic/higher education for nursing were considered to be largely administrative and practical in nature and not insurmountable. In fact, the symposium expressed its belief that student nurses are no different from other students in fitting into the general education system of a country. Where opportunity to study nursing within the system of higher education ofa country is lacking, students choose another profession within higher education and their education is paid for by govemment anyway. The movement of education for nurses into higher education would benefit the health services delivery in a country in many ways. Such benefits can be summarized as: feedback into health services in quahty of nursing care; increased motivation for young men and women to choose nursing as a career; increased job satisfaction; increased career hfe in nursing; the potential reduction of hospital utihzation when highly skilled nursing care is provided in the primary care system ofa country; greater potential for adaptabihty of health services to change; an increase in the quahty and contribution of nursing to the development of other health manpower for the health services delivery system; and a reduction in the waste of human and financial resources currently concentrated in post-basic nursing education programmes and devoted largely to filling gaps in traditional basic nursing education.
Symposium on higher education in nursing
433
The symposium discussed at some length the planning of change and strategies for bringing about needed changes in education for 'nurses'. Such strategies are discussed in detail in the final report ofthe symposium (World Health Organization 1973). Among the more important of the suggestions put forward by the symposium were the following: 1 Education for nursing should be provided in the general education system of the country and students of nursing should have the same rights and responsibihties as all other students in the educational system. 2 Young people seeking to become 'nurses' should meet the scholastic requirements for entrance into universities, colleges, academies and/or institutions affiHated with universities. 3 In countries where university education for nurses is not already the estabhshed pattem, plans should be made to move this education into universities, colleges, academies and/or institutions affihated with universities. 4 Universities which already provide equivalency examinations for mature students with work experience but lacking full admission requirements, should be encouraged by the health authorities to extend the same privileges to mature, experienced nurses seeking admission to universities. 5 It would be advantageous to the nutsing profession to explore the possibihties offered by different universities for the education of professors of nursing. This should include the education of nurse researchers andof nurse administrators with an interest in teaching in the chnical fields, who then would be quahfied to hold a dual appointment in the hospital and the university.
References BENDALL E . (1976) Learning for reality. Jowrna/ of Advanced Nursing i, 3-9. WORLD HEALTH ORGANIZATION (1966) World Health Organization Technical Report Ser., 347, 13. WORLD HEALTH ORGANIZATION, REGIONAL OFHCE FOR EUROPE (1973) Higher Education in Nursing,
Report on a Symposium, The Hague, 1972, Copenhagen.
