Running head: REGISTERED NURSES EDUCATION FROM 19TH CENTURY TO PRESENT 1
TheEvolution of Register Nurses Education
RegisteredNurses Education from 19thCentury to Present
Canadianpeople must be proud of their nursing profession that has bequeatheda legacy through vanguard of innovation in the healthcare industrysince the start of the nursing history. It is hardly incredible hownursing profession has evolved since 1874 to a highly capable andethical profession with reputation and standards, envious of otherprofessions. However, the evolution of the registered nurses (RN)education has not been an easy transition as nurses had to press forrespect, favorable working conditions and good compensation.Therefore, the successful evolution of the registered nurse educationcan be attributed to the history of the audacious women who, in spiteof societal expectations of marriage, dedicated their lives andefforts to improvement healthcare standard of their time. However,the origin of the Canadian nurses is associated with Jeanne Mance,who established Hotel Dieu Hospital. The nurses in Canada wereinformally trained and gained skills in domestic caring for ill.Formal education for nurses in Canada has evolved through economic,societal, military, and sociological influences (McPherson, 2006).Therefore, this paper discusses the evolution of the registered nurseeducation from 1874-1982, taking into account foundation anddevelopment of the nursing education, as well as the emergence of thepost-secondary nursing education.
1874-1920:The Foundation of Modern Nursing Education
Theevolution of the Registered Nurse Education started to emerge in theearly 1874. In the year 1874, the Mark School of Nursing wasestablished in St. Catherines. It was the first school in Canada toemulate the nursing system of the Florence Nightingale that wasfounded fourteen years back. Hospital-based schools adopted theNightingale nursing model since the economy was potentially capableof providing a reliable source of nursing labor. Therefore, hospitalsdeveloped schools while physicians and hospital administratorscontrolling nurse education programs. Additionally, physicians hadgreater determination in the performance and practices of nurses inthe clinical environment (McPherson, 2006). The fundamental goal ofestablishing nurse schools was to offer a steady supply of thosenurses who socialized in order act as well as think in favor ofpatriarchal superior’s wishes: obedient, well-disciplined, andpropensity to follow orders. Since the establishment of theapprenticeship of the nurse training models, there was a rapidexpansion of nursing institutions that led to the substandardcurricula, decrease in admission standards, insufficiently preparedinstructors, and lack of standardization in nursing schools.
In1889, a new General Hospital was opened in Toronto with its ownnursing school adopting the principles of Nightingale of 1874. Theopening of this nursing school paved way for the establishment of thenursing schools in Canada. Therefore, education to nurses at thistime was mainly caused by physician’s beliefs and values concerningindividuals in sickness and health. It is in order to urge that theideology of medical knowhow highly caused other forms of knowledge.Thus, main ideologies as well as discourses have contributed to theunderstanding of nurses about human beings, their sickness, health,and healing (Gleason, 2013).
Theapprenticeship nursing education determinedly established hospitaland medical administrator domination over nurse education. Based onthe self-sacrifice and service, commitment, duty, and subordinationto male physicians and administrators of the hospitals, theapprenticeship model of nursing resulted in poor social status andpay for the nurses. This apprenticeship model of nursing educationdid not contribute much in developing nursing knowledge ideology(Kirkwood, 2006). Nursing students were apprenticed for two to threeyears during which they provided labor to nursing hospitals inexchange for board and room, their education, and a small stipend. Itis clear that the expansion of hospitals in Canada relied on the freelabor offered by the student nurses.
Therefore,the evolution of the registered nurse education has largely dependedon the various most important pioneers in the development and growthof the early nursing schools (Cooper, 2009). Elizabeth Breeze is oneof the nurse education pioneers and was educated at the Hospital ofToronto for sick children. In 1910, Elizabeth Breeze went toVancouver City where she founded first nursing school in that area.As years passed, Elizabeth Breeze was the first Public Health Nursingdirector in Vancouver. Therefore, Elizabeth Breeze contributedgreatly in the field of nursing by establishing a nursing textbook,“Health Essentials for Canadians schools”, and this book was usedfor a period of twenty years. Another leader worth discussing is theBertha Harmer, who was educated in the General Hospital NursingSchool of Toronto in 1913. She was a teacher in nursing schools inCanada. She contributed greatly through her book entitled, "TheTextbook of the Practices and Principles of Nursing" (1923),which was regarded as the best nursing textbook ever written, and thebook was used up to 1934. Furthermore, during 1913, Jean Gunn wasbestowed a Superintendent nursing position at the General Hospital ofToronto. She dedicated her life for over twenty five years innurturing and respecting nursing profession in spite of thereactionary attitudes of doctors, politicians, and hospital trusteeswhom she worked with in her career. Therefore, the evolution of nurseeducation is filled with courageous women with inspiring ideas aboutnursing in healthcare, and they lived based on their own beliefs(Pringleet al., 2004). Additionally, there was provision for adult educationfor those women who wanted to obtain formal education during thetwentieth century. The propensity of the adult education was due tohigh number of women in Canada at that time practicing informalhealth care for the sick people. The adult education was known ascitizen education as it was human development learning (Dickinson,2003) .
Introductionof graduation brought stress and uncertainty among the nursingstudents. Very few nursing students could anticipate being employedin hospital institutions. By around 1914, nurses were over twentythousand in Canada majority of them could highly not get employed innormal nursing jobs (Keddy & Dodd, 2005). Fortunately, World WarI (1914-1919) provided temporary jobs for the most of the nurses asthey became military nurses within Armed Forces of Canada. It wasunfortunate that only twelve military nurses remained permanentlyemployed after the end of the World War I. However, nurses in privateduty, characterized by lack of good wage and job security, provided afew nursing job options only to the ‘respectable’ women (Keddy &Dodd, 2005). Therefore, most of the nurses worked so hard to changethe societal perception that nursing is an extension or wing ofdomestic chores. This societal perception towards women enabledhospital administrators to nurses as disposable workers. The idea ofwomen born nurse is notable in the way they were perceived in theworkplace. This ideology devaluates nurses and women since it lessenstheir much needed contributions to help the society and belittlestheir knowledge needed to undertake nursing work. Thus, nurses weregrudging paid for their work (Cooper, 2009).
Thepropensity to professionalize nursing education begun in 1915 justlike in the US, since nurse leaders in Canada were not comfortablewith the nursing education apprenticeship model. Therefore, they werein the need to professionalize nursing, and this was via professionalassociations, legislation and university level education process.However, Nurse leaders in Canada began to petition government for thelegislation in order to regulate nursing practice through dominantdiscourses and ideologies (McPherson, 2006). The nurse leaders wantedthe trained nurses to be registered as a way of making it possiblefor the public to differentiate them from the untrained andunregistered nurses. Therefore, the members of the public expectedthat the registered nurses to provide healthcare services with skill,knowledge, and care (Dick & Cragg, 2003).
By1919, nursing education at university level had been introduced inthe country due to contributions of RN during First World War as wellas influenza epidemics that occurred in the period between 1918 and1919. Therefore, nurses’ contributions helped to improve theirimage as trained nursing profession. Furthermore, Registered Nurseleaders accomplished most of the nurses’ grievances during thesefronts, in order to enhance nursing goals to acquire autonomousregistered education to nurses in the available universities withinCanada. The early university program of nursing education wasintegrated with hospital training (Dick & Cragg, 2003).Therefore, hospitals employed nursing students without applying togeneral education and training in clinical settings.
1920-1960:The Development of Nursing Education
The1920’s society, however, still related nursing profession to thenature ‘feminine’ characteristics of caring, and nurses inpersonal duty employment ought to offer the burden of nursing as wellas domestic duties (Keddy & Dodd, 2005). Therefore, nurse leaderspushed their initiative to have Registered Nurses (RN) throughregistration process (Canadian Nurses Association, 2005). By 1922,this initiative succeeded when all provinces in Canada succeeded inpassing legislation framework that governs nursing profession.Although nursing leaders achieved registered nurses throughlegislation process, they did not attain title protection. Therefore,nursing legislation at provincial level facilitated a standard forthe development at national level of the nursing curriculum inCanada. This registration of nurses helped in distinguishing trainednurses from lay nurses.
Dueto the development of the registered nurse education, most of thewomen were increasingly becoming aware of the fact that higher oruniversity education was only a way of eliminating socialinequalities between women and men. RN leaders acknowledged thathigher education standards gained through university education,especially technical education, would foster nursing sociallegitimacy (McPherson, 2006). However, discourses of nursing by thesociety as an extension of domestic chore was a huge barrier to theimplementation of the university nursing education. For instance,Toronto University came up with a course on household science,although they did away with a course on nursing hospital supervisors.Thus, majority of universities at that time acknowledged the role ofwomen in society. Therefore, women who got an opportunity of beingenrolled in university undertook dominant discourses and Ideologiesin nursing education psychology and, home economics programs. Theareas or programs of study made sure that, women would become betterwomen and wives, since they did not intimidate domestic duties ofwomen to their families.
In1932, Kathleen Russell introduced integrated nursing program atuniversities to advocate the autonomous in nursing education.Kathleen Russell was a Public health Director in the University ofToronto who pioneered integrated nursing programs, which was a newmethod adopted by most of the universities offering nursing educationprograms in Canada (Kirkwood, 2005). Rockefeller Foundation of UnitedStates provided funding to enable Russell implement a nursinguniversity degree program which could last for thirty nine months.This integrated nursing program enabled nursing faculty to acquirefull authority over clinical hospital practice and universitycurriculum. Furthermore, the integrated nursing program enableduniversities link general theoretical nursing principles to theclinical practice and experiences for the nursing student needs (Dick& Cragg, 2003). The intention of the Rockefeller Foundation wasnot promote nursing education, but to promote public health programs,as well as medical education. Therefore, nursing education was deemedas an auxiliary service to the objective of the RockefellerFoundation. Moreover, the Rockefeller Foundation noted that, thisprogram should be checked by the university and supported by themedical faculty. Consequently, nursing education was put under thismedical program. Moreover, the discourse of expert with medicalknowledge enabled continuous shaping of the nursing education. In1942, however, Russell attained her objective of granting nursingprogram a degree status after twenty years petitioning of universitythat had adopted dominant discourses and ideologies that affectedquality nursing education. Another example is that it took nearlytwenty years of struggle for the University of the Montreal toachieve the dream of the nurse educators to have a nursing facultythat was independent of the medical faculty (Dick & Cragg, 2003).
In1938, the Licensed Practical Nurse (LPN) was conceptualized. Thenotion of the LPN started due to the 1929-1933 Great Depression thatposed challenges to the Canadian nurses in getting paid employment.This is because of low income status of people due to the economicrecession (Keddy & Dodd, 2005). However, World War II of1939-1945 provided nurses with steady employment. It is reported thatover four thousand registered nurses were working in Canadian ArmedForces as military nurses during this warring times. Additionally,the political discourses due to the demand for nurses causedtremendous enrollment of women in nursing schools. In Second WorldWar, a number of nursing graduates increased with a rate of 40 percent (McPherson, 2006). Moreover, the Canadian Red Cross Society(Victoria Order of Nurses) offered loans and scholarships to theuniversity nursing students enrolled in nursing programs of publichealth and baccalaureate international schools (Hayes, 2007).However, it was no easy task to entice women into the nursingprofession since there was availability of reliable jobs that paidimmensely. Although there was a great effort of producing morenursing graduates, shortage of nurses in Canadian hospitalspersisted. Therefore, practical nursing as new nursing category wasestablished to counterbalance the Registered Nurse shortage. Thefirst province in Canada to enforce legislation and development ofpractical nursing education was Ontario (Pringle et al., 2004).Practical nursing was initially referred to nursing aides in theearly Canadian programs and was acquired through a six month basictraining. These nursing aides were employed in hospitals and homenursing institutions and were supervised by the registered nurses(RNs).
From1946 to 1950, there was Baby Boom in Canada and most of the nursesbenefited from the military service. Therefore, registered nurseleaders recognized the advantage of offering nursing services toCanadian military during Second World War to foster their objectiveof securing nursing education at university. Furthermore, the leadersof the nursing programs at university had established an associationwhich they named as Canadian Association of School of Nursing (CASN)in the year 1942, which was devised to press for university nursepreparation, build as well as implement standards for accreditationat the level of university (Dick & Cragg, 2003). In the yearsthat succeeded the second world war, Registered Nurse leaders arguedthat registered nurses had right to pursue higher education. Theyindicated that, on the basis of registered nurses’ role to the warin which they assisted wounded soldiers.
Theintroduction of the hospital insurance schemes in 1947 helped in therevolution of the registered nurse education in Canada. The hospitalinsurance schemes had been fueled by the world wars and the effectsof the Great Depression, which saw the discourses of the societyabout the necessity for overall social safety. Additionally, Canadiangovernment reacted by establishment of social welfare system. Thisstep further developed registered nurse education. In 1950, practicalnursing was regarded as behavioral and trade models of the registerednurse education. Therefore, in reaction to the dynamic needs ofhospitals, Canadian government amended the registration Act of theexisting nurses to give more room for the standardization andimprovement of the registered nurse education in1951 (Government ofOntario, 2005). This amendment allowed nurse leaders to considerundergraduate intra-professional programs, RN-LPN education programs,to nursing and healthcare systems. Moreover, the practical nursingeducational activities were shifted to training done in vacations inmost of the provinces during the period around 1950s (Pringle et al.,2004). In 1957, Education Department started by sponsoring practicalnursing.
1960-1982:The Rise of Post-Secondary Nursing Education
In1960, a registered nurse, Helen Mussallem, became sufficientlyconcerned about the status of the registered nurse education in thecountry, and advocated the review by federal of registered nursingeducation (Pringle et al., 2004). Therefore, the federal governmentestablished Health services Royal Commission in 1962, in response tothe Helen’s demand. The royal commission, also known as the HallCommission, it was given responsibility of undertaking acomprehensive review of the education programs pertaining healthprofession. Therefore, this was a fundamental opportunity for thenurse leaders and government of Canada to vigorously take intoaccount the undergraduate benefits emanating from RN-LPN education inthe healthcare system. There is no sufficient evidence that this wasdone, nevertheless. However, the commission recommended thatpractical nursing programs to be assimilated within RegisteredNursing (RN) programs, and consequently, practical nursing positionswere all over sudden eliminated (Pringle et al., 2004). For thisreason, Licensed Practicing Nurses (LPNs) were less considered asprofessionals, and they were seen as a threat to theprofessionalization of Registered Nurses (Canadian NursesAssociation, 2005).
In1968, WEA (Workers’ Education Associations) came up with new energyto integrate the worker’s or adult education to improve the healthcare services provided by the employed registered nurses. Therefore,many universities developed curriculum based on the Worker’sEducation Association (WEA) through extension departments, althoughas a realm of adult education saw adults enrolling to acquire nursingeducation rather than relying on the informal training. Thus, theadult education responded to the human needs to understand and havebigger picture of social context. However, the adult education inCanada did not survive for long because both professional educatorsand trade unions regard workers’ or adult education as politicalmotives and consequently, adult education was marginalized. This muchdocumented by the Jeffery Taylor about marginalization of WEA inCanada, although it was much influenced by the Americans (Dickinson,2003).
In1970, nursing education program changes from the focus of biomedicineand behavior to humanism. The curriculum was governed by theprinciples of the nursing theory. Therefore, the recommendationconveyed by the Hall Commission of shifting the responsibility of theRegistered Nurse education curriculum from hospitals to collegesbelonging to the community in 1970’s, comparatively decreasedhospital administrator and physician control over nursing profession(Dick & Cragg, 2003).
Theuniversities of Canada adopted the integrated system of nursingeducation programs. Additionally, the university educators were in aposition of coming up with nursing education curricula and standards.Therefore, university educators started to gradually shun away frombiomedical orientation. From this point forward, nurses began tounderstand human anatomy metaphorically as system with separate partsthat can be dissembled and treated autonomously from each other.Therefore, this is an excellent proof that registered nurse educationwas revolutionizing with an incredible rate. Through introduction ofbiomedical concepts in the nursing curriculum, nurses were able tokeep up with physician beliefs that healthcare personnel are expertsof patient’s care who takes care of the patient’s health andhealing requirements. Furthermore, baccalaureate internationalschools were also used as an entry requirement to the registerednurse practice position (Way & MacNeil, 2007). Also, registerednurse leaders had lifelong-held idea of university degree as aminimum grades for the nursing practice. However, acquiring thislong-term objective would further revolutionize registered nurseeducation as a course of achieving nursing professional requirement.In 1979, registered nurses in Alberta were the first registerednurses in the country to approval of baccalaureate degree as a leastentry requirement to nursing practices for the fresh graduates(Pringle et al., 2004).
AlthoughLPNs and RNs had been fixated with enhancing their own categories ofnursing, the reliable theory on LPNs discloses that there werechances to intra-professional RN-LPN education programs. However, in1970s, graduates of practical nursing were required to undergo RNprograms to acquire competencies in the nursing profession (Pringleet al., 2004). In the period between 1981 and 1993, circumstancesrose in Ontario to consider intra-professional RN-LPN system ofnursing education. However, the leaders of practical nursing calledfor the hurried review of curriculum of the practical nursing, sayingthat practical nurses were under-utilized, and their potentials wereunder-developed too. This observation presented yet anotheropportunity for the leaders of the LPNs and government to explore thefeasibility of the intra-professional education. In 1981, theorganization of the registered nurse education removed administrationof medication from the curriculum of the practical nursing, whileadding aseptic technique of developing medication prescription.Therefore, practical nurses did not make any perceptible developmentin their attempt to expand their nursing practice. Furthermore,associations and leaders of the registered nurses were not recognizedamong the supporters of the practical nursing. Later in years,administration of medication was readopted into the curriculum of thepractical nursing. More notably, legislative amendments grantedpractical nurses right to be use the word “nurse” as their titleand their formal title changed into Registered Practical Nurse fromthe title Registered Nursing Assistant (Government of Ontario, 2005).
Nursesincreasingly required life-long skills to adapt to the ever-advancingnursing science and health technology (Heller, Oros &Durney-Crowley, 2000). Therefore, registered nurse education offeredtime as well as material support required to nurture the skills whichenhanced competency in this practice. It is plausible to anticipatethat, the need to get a baccalaureate degree as a minimum entryrequirement to the registered nurse practice ahead of anycontemplation of the intra-professional RN-LPN program of education.The minimum requirements were finally endorsed by the leaders of theprofessional registered nurse (RN) bodies in all sectors ofhealthcare in Canada (Canadian Nurses Association, 2005).Furthermore, provincial governments had the authority to establishthe legislation changes required by the bodies regulating thispractice in order to enforce entry to nursing practice needs. Themain focuses of regulatory bodies to make sure that, the citizens areprotected through development of competent nursing workforce.Therefore, all these reforms and changes that have occurred inpost-secondary nursing education, which contributed greatly in thefuture of the registered nursing education (Heller, Oros &Durney-Crowley, 2000)
Conclusively,healthcare reforms have impacted profoundly on the evolution ofCanadian registered nursing education. Therefore, these reforms haveprovided suitable context where cross-examination of the dominantideologies have led to shaping social, economic and politicalenvironment that have affected decisions about registered nursingeducation programs in Canada. Furthermore, the knowledge obtainedfrom dominant ideologies has helped leaders of the RN to understandkey areas that need improvement in nursing practice. This has helpedin getting the basis for considering directions and goals ofeducation envision for the future of the registered nursingeducation. From the above, it is clear that, the evolution of theRegistered Nurse Education started to emerge in the early 1874. Inthe year 1874, the Mark School of Nursing was established in St.Catherines. It was the first school in Canada to emulate the nursingsystem of the Florence Nightingale that was founded fourteen yearsback. Hospital-based schools adopted the Nightingale nursing modelsince the economy was potentially capable of providing a reliablesource of nursing labor. In 1889, a new General Hospital was openedin Toronto with its own nursing school adopting the principles ofNightingale of 1874. Later, the opening of this nursing school pavedway for the establishment of the nursing schools in Canada.Introduction of graduation brought stress and uncertainty among thenursing students. Very few nursing students could anticipate beingemployed in hospital institutions. By around 1914, nurses were overtwenty thousand in Canada most of them could not get employed inregular nursing jobs. Later, the introduction of the hospitalinsurance schemes in 1947 helped in the revolution of the registerednurse education in Canada. The hospital insurance schemes had beenfueled by the world wars and the effects of the Great Depression,which saw the discourses of the society about the necessity foroverall social safety. Additionally, Canadian government reacted byestablishment of social welfare system.
Fromthe 1960, the government of Canada permitted hospital administrators,hospital boards, and physicians to determine what nursing is ought toconstitute. The economic benefits provided by the student labor tothe hospital took priority, and nurses had no say in their place ofwork. The nursing programs provided by the universities remainedunder medical programs up to 1960. However, in 1938, there wereshortages of registered nurses in Canada, the fact that lead led tothe establishment of the Licensed Practical Nurse category tocounterbalance the shortage. This establishment provided transientsolution to the war time as wounded soldiers needed medical attentionand nursing services. Therefore, licensed practical nurses wereoriginally trained to help registered nurses. By 1970’s, hospitalsdiscarded the idea of educating nurses as they found that the programwas not cost-effective. Therefore, provincial governments shiftedthis obligation to the education ministry. In 1982, the nationalregistered nurse (RN) association of Canada (CNA) gave its stand thatthe baccalaureate degree is the least entry requirement to nursingpractice for the registered nurses. By the end of 1982 this objectivehad not yet achieved in all Canadian provinces.
CanadianNurses Association (2005). Entryto practice. Retrieved July 26, 2007, from www.cna-nurses.ca
Cooper,E. (2009). Creatinga culture of professional development: A milestone pathway tool forregistered nurses.Journal of Continuing Education in Nursing, 40(11), 501-510. doi:10.3928/00220124-20091023-07
Dick,D.D., & Cragg, B. (2003). Undergraduateeducation development and politics(pp. 182-204). Philadelphia PA: Lippincott, Williams &Wilkins.
Gleason,M. L. (2013). Smallmatters: Canadian children in sickness and health, 1900-1940.Montréal: McGill-Queen`s University Press.
Governmentof Ontario (2005). Ahistory of nursing in Ontario.Toronto: Author. Available from http://www.health.gov.on.ca
Hayes,L. J. (2007). Recruitmentstrategies for baccalaureate nursing schools in Ontario.Journal of Nursing Education, 46(6), 261-268.
Heller,B.R., Oros, M.T. & Durney-Crowley, J. (2000). Thefuture of nursing education. Ten trends to watch.Nurses Health Perspect. Jan-Feb21(1):9-13
Keddy,B., & Dodd, D. (2005). Thetrained nurse: Private duty and VON home nursing.In C. Bates, D. Dodd, & N. Rousseau (Eds.), On all frontiers:Four centuries of Canadian nursing (pp.43-56). Ottawa: University ofOttawa Press.
Kirkwood,L. (2005). Enoughbut not too much: Nursing education in English language Canada(pp.183-196). Ottawa: University of Ottawa Press.
McPherson,K. (2006). Bedsidematters: The transformation of Canadian nursing,1900-1990. Toronto: University of Toronto Press.
Pringle,D., Green, L., & Johnson, S. (2004). Nursingeducation in Canada: Historical review and current capacity. Ottawa: The Nursing Sector Study Corporation.
Way,M. & MacNeil, M. (2007). Baccalaureateentry to practice: A systems review. The Journal of ContinuingEducation in Nursing,38(4), 164-169.
Dickinson, T. D. (2003). Community and the world: Participating insocial change. New York: Nova Science.