olJ10-7489. V? S! w - 0.0 E IW? Pergamon Pros Ltd

The developing discipline of nursing from a Dutch perspective J. C. M. H. DIEPEVEEN-SPEEKENBRINK,

M. Phil., B.S.N., R.N. Project

Director

for Nursing Science. Faculty of Medicine, University of Utrecht. The Netherlands

Abstract-This article is based on a literature review and presents an overview of the development of nursing from vocation to a science based profession. It first addresses the start of formal nursing education in The Netherlands and then focuses on the developing academic discipline, which originated in the U.S.A. While the main focus is on The Netherlands, major milestones in other countries are also briefly discussed IDiepeveen-Speekenbrink (199Ob), “The need for graduate nursing education and nursing research in The Netherlands: An exploratory study”, a dissertation for degree of Master of Philosophy at University of Wales College of Medicine].

Introduction

“It neveroccurred

to the Aristoteles of the past that it would be safer for the public welfare if nurses were educated instead of lawyers. The untrained nurse is as old as the human race; the trained nurse is a recent discovery. The distinction between the two is a sharp commentary on the follies and prejudices of mankind” (Robinson, 1946, cited by Donahue, 1985, XVI.)

During the past few decades nursing in Europe has undergone profound changes. In addition Europe’s borders are fading. International study programs, student and faculty exchange and many other international professional events bring nurses together on a more regular basis enabling enriching international networking. Contacts with colleagues from other countries and a wealth of international professional literature demonstrate how global a profession nursing is. Amongst many matters it is evident that numerous countries struggle with the evolution of the profession and with the concept that nursing practice should be science based in order to cope adequately with today’s and tomorrow’s health challenges.

The beginning

in The Netherlands

The Dutch history of nursing reveals that the first initiative towards formal education for nurses started in the 1870s. Pioneers to be mentioned in this respect are Jacobus Penn, 99

W. M. Gunning, Jeltje de Bosch Kemper, Anna Reynvaan and Aletta Jacobs. Regretfully it would be difficult to mention all the names of the many who made valuable contributions to the early developments, enabling the first educational program to start in 1878 in two hospitals in Amsterdam. The first Dutch draft law concerning nursing was presented in 1920, accepted by parliament on 16 March 1921, and formally became effective on 1 January 1924. This law, which is still effective today is usually referred to as the law of 1921. Reports stressing the need for change started to appear as early as the 1930s. In 1932, the national nurses association of the day (Nationale Bond van Verplegenden) published a plan for improvement of the educational program, pleading for 770 hours of theoretical teaching and additional courses to those given by physicians and nurses. It is interesting to note that in this report male nurses were not considered as full value nurses. They were only needed for male patients and a short program was recommended. The report also differentiates between basic and post-basic education. This report was followed by another in 1935, published by the advisory committee on nursing of the day (Raad voor Ziekenverpleging). It mentioned for the first time that nursing education should be more than a vocational training and therefore should be offered not only for hospitals, but also “and in particular” for society as a whole. This statement should be regarded with reservation. Apparently it referred more to the protsction of nurses than to the value of nurses for the health care of the entire population (Binnenkade, 1973). Other characteristics of this report were suggestions with regards to admittance criteria and examinations. While World War II silenced public discussions about necessary changes, these started again almost immediately afterwards. From now on one encounters, more and more often, the idea that student nurses should have a proper education rather than be an employee as well as a trainee. Differences in opinion about the most desirable form of education also begin to show (Sanders, 1951; Hammenga, 1983; Binnenkade, 1973). Discussions about the need for differentiation between first and second levels in nursing and nursing education as well as about independent schools vs apprenticeship hospital schools developed seriously during the 1950s and 1960s (van de Ven, I97 1; Verbeek, 197 1, 1974; Meyboom, 1971; von Nordheim, 1971; Post, 1971; Graamans, 1972). Present day nursing education

in The Netherlands

Apprenticeship education vs independent schools History reveals that the discussions about apprenticeship education vs education in independent schools of nursing date as far back as before World War II. Frederique Meyboom, one of the country’s leading nurses, already pleaded for independent schools in 1915 (Hammenga, 1983). In 1949 and 195 1 two important committees advised the government about necessary changes. The committee chaired by Sanders was quite clear in demonstrating the tensions between service needs and educational needs and defended the stance that student nurses should be educated, at least for a basic period, in schools. The committee also put forward the viewpoint that the Minister for Education should be responsible for nursing education rather than the Minister for Health Care being responsible (Sanders, 1951). The entire report is interesting and thorough and demonstrates knowledge of developments in other countries. It even mentions university education in nursing such as it already existed in the U.S.A. As will become clear, the discussion about what is best is still current today, almost 40 years later.

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schools

Hammenga (1983) relates how many sequential royal decrees were added to the 1921 law, without changing the basic concept of apprenticeship education. Notwithstanding undeniable improvements, the objections to this type of training (rather than education) became more and more evident in the 1960s and 1970s. (a) Undergraduate higher education (i$BO- V). The formal discussions between health care organizations and the government about undergraduate higher education in nursing started in 1966 and led to the installation of a formal committee called “Commissie Hogere Beroepsopleiding Verpleging” (Committee on Higher Professional Education in Nursing). This committee presented its final report in 1969 and the first two programs in undergraduate higher education started in schools in Leusden and Nijmegen in 1972. Today there are 18 such programs, offered by schools of higher professional education, where students are students in the true sense of the word. Since changes in law in 1987, students of these programs earn a baccalaureate degree upon completion of their studies. At present there are about 7000 graduates of this kind, whereas the total working nurse population is estimated to be approximately 122,000. These figures gain significance when compared with recent studies showing that in 1988 approximately 22 per cent of all newly registered nurses had completed baccalaureate education, against 10 per cent 5 years earlier (van der Windt, 1988). (b) Education of the second level nurse. The discussion about the need for differentiation between first and second level nurses dates from the same period, and in 1970 another committee was installed. It was the committee “Van Nordheim” named after the chairman. The assignment was to investigate whether: - the different types of basic education could be integrated; - the entrance age could be lowered in order to enable direct entry after secondary school; - a division could be brought about between trainee and employee (learner and worker); - the duration of the program could be shortened. This committee’s final report, presented in 1971, became the basis for formal second level education, which, as the first level undergraduate higher education, also started in 1972. Today there are 12 such second level programs, offered in independent schools (Hammenga, 1983; Brand, 1979) for vocational education, where students are also students in the true sense of the word. The continuous discussion

Notwithstanding the important moves of nursing education into independent schools, for both first and second level education, the main model of nursing education in The Netherlands is still the apprenticeship model. After many years of controversial discussions the government decided in 1980 to end apprenticeship education. In principle, nursing education was to become true education offered in independent schools, either for higher professional education or schools for vocational education. Unfortunately a time table for the execution was omitted. In addition the government pronounced the condition that restructure should not demand any extra expenses, To date this formal government decision has not been effected and the controversial discussions still continue. Many describe the present situation as undesirable, chaotic and bad for all concerned and plead for the immediate execution of the 1980 decision (Dassen, 1986a,b,c; Horenberg, 1986; NRV, 1986; Bakker, 1987). In April 1988 a group of nurse leaders, known as the “Den Treek” group (named after

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the group’s conference site) published an advice for a new structure for basic education in nursing. In summary the report entails the 1980 government decision as well as a plan and a time table for its realization. According to the views of the committee the process of restructuring should be completed in 1995. The “Den Treek” report may be considered as a serious attempt to solve the present deadlock. It was well received by many, but also caused as many negative reactions. In mid-1988 van der Windt (1988a,b) demonstrated that there was to be a serious manpower shortage in nursing in the near future and pleaded for a clear educational structure encompassing all forms of basic education. Towards the end of 1988 the Dutch National Hospital Association (NZR) expressed its views on the matter and in March 1989 published a plan which, however, focused on the solution of future manpower shortage in nursing, rather than on restructuring basic nursing education. Ankone (1989) writes that, amongst other matters, the negative light that the “Den Treek” report had shed on apprenticeship nursing education was one of the causes to make a stand. She reports that the NZR wishes to focus on optimum use of all available resources and considers further discussions about the best type of education undesirable. In these publications the stance towards nursing education in independent schools is supportive. The main theme, however, is future manpower shortage rather than the most desirable education for student nurses. Registration Questions might have arisen about registration. Therefore the following information is added. (a) Registration as first level nurse. Today there are three types of apprenticeship education leading to state registration as a first level nurse: - apprenticeship education towards registration as a general nurse (A-opleiding); - apprenticeship education towards registration as a psychiatric nurse (B-opleiding); - apprenticeship education towards registration as a nurse of the mentally retarded (Z-opleiding). In addition, undergraduate higher education (HBO-V) leads to registration as a first level nurse. (b) Registration assecond level nurse. Formally there is one route of education leading to state registration as a second level nurse, which is the education offered in the 12 vocational schools mentioned earlier.

The birth of the academic

discipline

of nursing

While modern nursing clearly had its roots in Europe, where Florence Nightingale played such a leading role, the academization process started at the turn of the century in the U.S.A. (Bergman, 1986a,b), where in 1899 the first university program for nurses was created at the Teachers College of the Columbia University. It was a course in hospital economics for nurse leaders and did not yet lead to a degree. The first program towards the baccalaureate degree began in 1916. After that several other universities followed the example. Another milestone at Teachers College was the appointment in 1907 of M. Adelaide Nutting as the world’s first Professor of Nursing (Parietti, 1979; Donahue, 1985). This is only one side of the picture. The other side shows that in the U.S.A. schools of nursing began to develop in the 1870s with the establishment of three Nightingale Schools

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of Nursing at Bellevue, New Haven and Massachusetts General Hospitals (Rawnsley, 1973; Hogstel and Sayner, 1986). However, the Nightingale philosophy did not really thrive and by the turn of the century hospital-controlled apprenticeship training had become the predominant model of nursing education (Bramadat and Chalmers, 1989). Schools differed greatly in quality and shortly after World War I nursing and nursing education seemed to be in serious trouble. The Goldmark Report, which was conducted between 1920 and 1923, brought to light many shortcomings, offered clear conclusions and eventually brought about significant changes (Rawnsley, 1973; Kelly, 1985; Donahue, 1985; Abdellah and Levine, 1986; Hogstel and Sayner, 1986). One of the most important outcomes of the study was the establishment of a number of university schools that first offered only baccalaureate programs. Donahue (1985) distinguishes the following stages in academic nursing education: 1939-1952: Increase of baccalaureate programs. 1953- 1964: Transitional stage. During this period, Master’s education was recognized as the desired level of advanced nursing education. 1964-1975: Maturation of Master’s education. The (relatively slow) start of doctoral education in nursing is traced back to 1920, when the Teachers College of Columbia University initiated the first doctoral program, which led to an Ed.D. (Educational Doctorate) in nursing education. Today two types of doctoral degree programs are known: the Ph.D. or academic doctorate and the D.N.S. or professional doctorate. The Ph.D. programs emphasize nursing research, while the D.N.S. programs stress practice. The evolution of nursing research The pioneer nurse Florence Nightingale is frequently referred to as the first nurse researcher, since her reforms were based on careful investigations and on presentation of clear statistics. In recognition of her achievements, she was actually made fellow in the Royal Statistical Society in 1858 and became honorary member of the American Statistical Society in 1874 (Donahue, 1985; Hogstel and Sayner, 1986; Polit and Hungler, 1987). Many authors indeed begin their review of nursing research with Florence Nightingale (Hogstel and Sayner. 1986; Abdellah and Levine, 1986; Polit and Hungler, 1987). They also indicate that in the first decades after her death little is found in the nursing literature about nursing research. During the 1920s important studies were done in the U.S.A. on nursing education at the request of the National Organization for Public Health Nursing. The results were published as the Goldmark Report and revealed many inadequacies in nursing and nursing education. More studies on nursing and nursing education followed between 1920 and 1940. In the 1930s other disciplines, such as psychology and sociology, started to study nursing. During the 1940s studies on nursing education continued and gradually began to bring about changes. During this decade researchers also started to investigate topics such as the demand and supply of nurses, the status of nursing and the environment in which nurses worked (Hogstel and Sayner, 1986; Abdellah and Levine, 1986; Polit and Hungler, 1987). The origin of practice related research is traced back by Gortner and Nahm (1977) to the late 1920s and 1930s. while the real breakthrough of academic nursing research seems to have occurred in the 1950s (Hogstel and Sayner, 1986; Meleis, 1985; Abdellah, 1986). This is understandable since before 1950 only 30 North American nurses had earned a

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Doctorate degree, whereas by the end of the 1960s this number had grown to over 500 and by 1975 had passed 1000 (Schlotfeldt, 1975). In 1984 approximately 0.8 per cent of the nation’s close to 1,900,OOOregistered nurses had earned a Doctorate degree (NLN, 1986a,b) and nursing research is now acknowledged as a must for the profession (Abdellah and Levine, 1986).

Developments in other countries

Discussion in depth of the developments in other countries is beyond the scope of this article. Some milestones, however, are highlighted as illustrations of the evolution of nursing. United Kingdom

In the U.K. the Department of Nursing Studies of the University of Edinburgh was created in 1956. The first undergraduate program started there in 1960 and at present both undergraduate and graduate courses are provided. The Nursing Research Department was established in 1971 (University of Edinburgh, 1986). Manchester University was the second to start with a Bachelor of Nursing Degree Course in 1969 and the University of Wales commenced its first Bachelor of Nursing Degree Course in 1972. The aim of this course in Wales was: I‘. . . to assist ‘vertical expansion’ by bringing to the profession more trained minds with a broad outlook, to provide leaders and teachers of a high professional standing, capable of the objective and analytical approach required in the increasing numbers of positions in nursing administration, teaching and research, at national and international levels, and to attract to the profession those who find the present training intellectually and Chapman, 1988).

unsatisfying and so take up other careers” (Bircumshaw

The first part-time Master of nursing degree course of the University of Wales commenced in 1984 and provided the opportunity for nurses to study their profession at an advanced academic level (University of Wales, 1988). Since the successive start at the Universities of Edinburgh, Manchester and Wales there has been an impressive development in the U.K., although the main emphasis seems to be on developing undergraduate programs (Smith, 1988). Israel

Bergman (1986b) relates how Israel’s first initiatives towards academization of nursing education started in the 1960s. The first university program for registered nurses was opened in 1968 at Tel Aviv University. It was a post-basic program leading to a baccalaureate degree. The major purpose, according to Bergman, was to create infrastructure for academization. By this she understood the preparation of teachers and the adaptation of clinical areas for the future generic baccalaureate. Additional objectives were the creation of graduate programs, aimed at expanding the body of nursing knowledge, and the contribution to the health system through continuing education programs and community planning. Bergman (1986b) further relates how leading Israeli nurses have achieved a major goal with the official acceptance of a 25 year plan aimed at baccalaureate education in nursing as the only professional preparation. If all goes well, professional nursing education will be by university education only by 1995 and diploma schools will no longer exist. According to Bergman (1986b) this evolutionary approach permits conversion of available facilities, upgrading of faculty to university level and acceptance of higher education by related services and other disciplines.

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Finland

Sinkkonen (1989) demonstrates that in Finland the development has been quite impressive in the 1980s. University education in nursing and other caring sciences started in 1979 at the University of Kuopio, with a Masters degree program in nursing education. As of the autumn of 1987 seven of the country’s 17 universities offered Masters degree programs in nursing and allied fields. There are also post-graduate degrees: the licentiate and the doctorate degree. Apparently the programs leading to these degrees are quite similar. The main difference is the thesis work, which is scientifically more demanding for the doctoral dissertation than for the licentiate thesis. Sinkkonen (1989) reports that a significant landmark for nursing was the establishment of full professor’s chairs. In 1985 the first three were created at the Universities of Helsinki, Kuopio and Tampere. Later the Universities of Oulu and Turku followed. By the end of 1987 Finland had seven chairs in nursing science.

University

education

in nursing and nursing research in The Netherlands

In discussing university education in nursing in The Netherlands it should be noted that, since changes of law in 1985 and 1986, legally higher education encompasses education at the schools for higher professional education as well as university education. Undergraduate education is offered only at the schools for higher professional education and university education exclusively at the universities. Thus, according to Dutch law, undergraduate education is higher education, but it is not university education. Undergraduate degrees are provided only by the schools for higher professional education and Master’s and Doctorate degrees are granted by universities (Diepeveen-Speekenbrink 1990a,b). Before 1980 The need for university education in nursing and for nursing research began to get serious attention in the early 1970s when a group of leading Dutch nurses formed a working group aimed at preparing a first plan for university education for nurses. The group’s first interim report was presented in 1975 (Werkgroep Universitaire Opleiding van Verpleegkundigen, 1975). The publication was followed by the installation by the government of a formal working group, which presented its final report in 1979, that recommended the start, as soon as possible, of university education in nursing. An interesting detail is that the minister of education of the time had granted, to the surprise of all concerned, permission for the start of such a program at the University of Limburg shortly before the group had presented its final report to the government! There clearly were political reasons for this procedure. Meanwhile several non-nurse educational experts had started to address the issue in writing. In 1976 de Haan argued that university education in nursing was necessary because of: - the educational needs of teachers of nursing; - the need for nursing research; - the educational needs of nurses holding management and policy making positions in health care. He demonstrated that teachers in nursing need (more) fundamental knowledge of nursing, that hands on nursing care calls for a scientific knowledge base, and that all nurses holding top management positions need to know how to approach matters academically. There

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is, he argued, hardly a decision in health care that does not affect nursing. He finally recommended departments of nursing studies as part of faculties of medicine because of the intimate relationship between medicine and nursing (de Haan, 1976). Stolte supported this train of thought by arguing that university education for nurses was an urgent matter. Due to the advances in medical and related sciences, nursing care requires extensive knowledge and skills. Society, the government, patients and disciplines related to medicine and nursing become more and more demanding. Nurses need to take complex decisions, which often entail far reaching consequences. In turn, these require further development of knowledge and skills. Nursing is becoming more and more independent. However, the contribution of nurses themselves to the necessary changes have remained modest. Changes have, more often than not, been forced on nursing by other disciplines. Stolte, at the time a professor of medicine and an expert teacher, concluded that it was high time to address nurses and urge them to act. After all he said, it is their business and it is urgent (Stolte, 1978). Also in 1978 Hattinga Verschure er nl., at that time Professor of Hospital Sciences at the University of Utrecht, published three articles on the matter. The series commences by reviewing the recommendations for university education for nurses by the formal government committees mentioned before. The authors, however, consider the arguments in these reports as weak and fragmentary. They have the impression that the improvement of the status of nursing might have been one of the committees’ motives to plead for university education. They challenge that other countries like the U.S.A., U.K. and Canada already have university education and continue with explanations about the differences in educational systems. Their high opinion of Dutch university education seems somewhat biased. They also address matters such as the image of nursing, conceptions about science in general and nursing in particular and finally consider that the essence of nursing is caring. A scientific approach of caring, according to their views, would certainly be justified. Their reasoning leads to the conclusion that the faculty of Social Sciences should be the mother faculty of nursing studies, and preferably not the faculty of medicine. They recommend an immediate modest start (Hollands ef al., 1978; Bergen et al., 1978; Hattinga Verschure et al., 1978). In 1980 the University of Limburg started with the first Dutch program in Nursing Science. This was the result of a decision of the Minister of Education in February 1979. At the time this decision caused widespread disappointment and opposition, where it was argued that this program would not lead to registration as a nurse. These reactions were verbalized quite clearly by Verbeek, one of the Dutch nurse leaders in education of the time. In an address at a graduation ceremony, that was later published as an article, she states: “The master in nursing science is not a nurse. For those who hear this for the first time it will be as much a shock as it was for me; those who knew it already will be as appalled as we are .” (Verbeek. 1979).

She severely criticizes this route of academic studies, which is in no way in accordance with what nurses want and need. What we need, she states, is university education in nursing for nurses who well know the practice of nursing. We do not need academics without professional expertise in nursing. She argues that the three areas in which the future graduates of the University of Limburg are to work are management, education and research. These areas need nurses who combine university education with professional expertise. She finally calls for unity within the nursing profession in an attempt to find solutions that could bring about a change of policy (Verbeek, 1979).

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A few weeks later Wijnen (1979), at that time rector of the University of Limburg, reacted with an article that shows an understanding of Verbeek’s and others’ disappointment, as well as appreciation for the need for university education for nurses. He addresses the entire changing system of higher education and searches for solutions. Wijnen remarkably proposes that graduates in nursing science could obtain registration as a nurse by following an HBO-V program, which in fact would mean an undergraduate education after completed graduate studies. HBO-V graduates in turn could obtain exemption of parts of the nursing science program. During this turbulent period Hopman (1980) presents a valuable contribution to the ongoing debate. Hopman is a pedagogue with many years of teaching experience in the initial higher education programs in nursing of the 1970s. Earlier his doctoral dissertation on education in nursing had been well received (Hopman, 1970). In the introduction of his 1980 work one reads his concern about the Limburg program. It is clear to him that opinions are quite diverse and that the issue requires a worthy discussion. He reveals his attempts to initiate such a discussion and his hesitation at starting his 1980 study. Why should a pedagogue write about university education in nursing? He admits having serious reasons for doing so. First of all, his many years of work with nurses have convinced him of the need to upgrade the practice as well as the theory of nursing. At the time many nurses went abroad for university education. His second reason was the recent government decision allowing the Limburg program and the disappointments and discussions which it had brought about. It is obvious that Hopman is concerned and wishes to contribute to the potential development of nursing science. He confides his great admiration for Frederique Meyboom, who had stressed in writing, in 1970 when she was already over 100 years of age, that he should continue to work towards the establishment of university education for nurses. In this study Hopman presents an interesting review of the history of health care and nursing education in The Netherlands: he analyzes the past systems and problems as well as those of the day. He devotes a chapter to practice and science, discusses in depth university education in nursing and criticizes the foreseen Limburg program. He adds, however, that notwithstanding the differences in opinion and the problems to be overcome, it is of immense importance that the program should start. The future will show what should be learned from both right and wrong initial decisions. Finally, he presents 10 theses. In summary these strongly support academic education, since modern nursing needs a body of scientific nursing knowledge. Other disciplines should not be permitted too strong a voice in further developments. The nursing profession itself should take matters in hand. If need be foreign nursing experts can be invited as consultants to assist in the creation of academic programs and to temporarily assume key positions. Eventually, students with high intellectual qualities will evolve to become teachers. Hopman finally suggests that the development of the science of nursing will continue. Maybe the process of maturation will be (too) slow, but nursing will become a full value academic discipline amongst other academic disciplines (Hopman, 1980). A few more demonstrations of concern and suggestions for a change of policy appear. Then all remains quiet for a while. The 1980s

The Dutch literature shows a gain of momentum as of 1984 (Diepeveen-Speekenbrink, 1987) following a symposium called “The Nursing Profession on the Move”. The event

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led to the first serious discussions about the possibility of establishing academic nursing education and research in Utrecht. A next important move was seeking out whether the Dutch government would support a project on this subject. This was vital since government permission was mandatory and essential in obtaining the necessary funds. The first reactions were disappointing and led to delay. Meanwhile Verwey’s (1983) research demonstrates a need for graduate education for nurses with higher professional education (HBO-V). The existing specialization courses as well as the post-basic courses in management and innovation do not suffice and do not lead to a Master’s degree. The 1986 conference “Changing Patterns in Nursing Education” turned out to be a new impulse, mainly because it led to sincere interest on the side of the board of the Faculty of Medicine of the Utrecht University and exploratory discussions about the establishment of a nursing education program were renewed. Shortly afterwards the board of the Faculty of Medicine took the necessary decisions and the project towards academic nursing education and research was on its way by the end of 1986 (Diepeveen-Speekenbrink, 1990a,b). Three other important publications that received a great deal of attention were: - The “Nota 2000” (Dutch Government, 1986); - the final report of the so-called “Commissie Vorst” (named after its chairman, 1987); - the so-called “Nota Dekker” (named after its chairman; Dutch Government, 1987). All three demonstrate that advances in medical and related sciences, medical technology, the (changing) structure of Dutch health care, demography as well as morbidity of the population have greatly influenced and changed health care during the past few decades. They also indicate important changes for nursing. Nurses will need to deal more and more with complex health care issues and have responsibilities of increasing importance. This requires increased knowledge and skills. The discipline of nursing, however, has not kept up and specific professional academic qualifications are lacking (Diepeveen-Speekenbrink, 1988; Landelijke Werkgroep Verplegingswetenschap Maastricht-Utrecht-Groningen, 1988). It is of interest to note that the memorandum by Vorst (1986). which deals specifically with education for health care disciplines and recommends policy changes, indicates a need for improvement of basic education in nursing. While expansion of undergraduate higher professional education is recommended, nothing is said about graduate education nor about nursing research! During the mid-1980s Dutch nurses clearly began to indicate their need for academic studies and in order to convince decision makers of this need surveys were performed in Groningen and in Utrecht. The Groningen working group Nursing Science (Werkgroep Verplegingswetenschap, 1988) reports that nursing practice calls for two types of university educated nurses: - the nurse specialist; and - the nurse manager. In addition the Groningen study shows a need for nurse teachers with university education. In the conclusions a program in nursing science at the University of Groningen is recommended. Conclusions of the Utrecht survey are summarized as follows (Diepeveen-Speekenbrink, 1988; 1990a,b): - there is a strongly felt need among nurses for graduate professional education; - a program offered in the center of the country (city of Utrecht) is valued hjghiy;

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the planned Utrecht program seems to meet the needs of those interested; - a high percentage of the potential students meet the educational entrance criteria; - a high percentage of those interested hold leading positions in nursing; - there is a clear task for the Dutch universities to offer graduate education in nursing and facilities for nursing research. Another relevant question was to learn how in turn directors of health care institutions and decision making boards view the need for higher education for nurses. A survey performed among this group revealed the following: - the input of academically educated nurses is strongly needed in multidisciplinary health teams; - there is a great need for nursing research; - nursing activities should be based upon scientific nursing knowledge; - scientific nursing education will contribute positively to health care; - scientific nursing education will contribute to the process of professionalization of nursing; - nurses in leadership positions need higher education; - The Netherlands is in this respect behind internationally (Diepeveen-Speekenbrink, 1988; 1990a,b). The next major events to be reported are firstly the start in September 1987 of the part time Master’s degree program for graduate nurses at the University of Limburg (Maastricht), secondly the start of the part-time Master of nursing degree course of the University of Wales in Utrecht in October 1988 (Diepeveen-Speekenbrink, 1990), and lastly the start in September 1990 of a joint national part-time Master’s degree program at the Universities of Limburg, Utrecht and Groningen. These events might prove to be a breakthrough after the controversial start in 1980. The

value of higher education

in nursing

In different countries the value of higher education in nursing has been investigated. summary, conclusions emerging from follow-up studies, done in the U.K. (Universities Edinburgh, Hull and Wales) reveal that: graduate nurses make a substantial contribution as nurses to the nursing profession; this contribution appears to be of significant different nature to that of non-graduate nurses; - the retention in the work force is clearly of a longer duration (Scott Wright ef al., 1977; Sinclair, 1984; Kemp, 1985; Bircumshaw and Chapman, 1988). Studies performed in Israel reveal similar findings. Apparently all reports are quite positive and demonstrate raised standards in education, in services and in the quality of care (Bergman, 1986b).

In of -

In conclusion

This was a helicopter view on the development of the nursing profession and nursing science in The Netherlands, where progress is still hampered by the struggle to find a compromise between service and education. As in many countries the professional preparation of nurses is still a matter of vivid, often controversial debate. There is also widespread dissatisfaction about the present day educational system. The move into higher

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education also demonstrates universal traits. Several studies clearly reveal the positive values of higher education. This implies that decision makers as well as the profession must each accept the responsibility for shaping the future in such a manner that nursing education, nursing research and the organization of nursing care services can meet today’s and tomorrow’s needs. “Research, education and practice are highly interdependent; serve as a resource and draw upon each other for inspiration

they enhance and enrich each other; and development” (Bergman, 1990).

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