5CHAPTER 1

History of Nursing Education in the United States

Susan M. Ervin

OBJECTIVES

Upon completion of Chapter 1, the reader will be able to:

OVERVIEW

The adventure that is labeled nursing education began at the close of the U.S. Civil War when it was recognized that nursing care was crucial to soldiers’ survival and that nurses must have some formal education. Using Florence Nightingale’s model of nursing education, hospital-based nursing programs flourished throughout the 19th and well into the 20th century. With few exceptions, however, Nightingale’s model was abandoned and hospital schools trained students with an emphasis on service to the hospital rather than education of a nurse.

Early nurse reformers such as Isabel Hampton Robb, Lavinia Dock, and Annie W. Goodrich laid the foundation for nursing education built on natural and social sciences and, by the 1920s, nursing programs were visible in university settings. World War I and World War II underscored the importance of well-educated nurses and the Army School of Nursing and the Cadet Army Corps significantly contributed to the movement of nursing education into university settings.

6Associate degree programs developed in the 1950s as a result of community college interest in nursing education, while Mildred Montag’s dissertation related to the preparation of a different type of nurse. The situation of nursing in community colleges, along with the American Nurses Association (ANA) proposal that nursing education be located within university settings, sparked a civil war in nursing that has yet to be resolved.

By the latter half of the 20th century, graduate education in nursing was established with master’s and doctoral programs growing across the country. Graduate education continues to strengthen the discipline as it moves into the 21st century.

IN THE BEGINNING

American nursing programs changed dramatically over the past 150 years in response to milestones such as world wars, the Great Depression, and changing U.S. demographics. The initial milestone that catalyzed the founding of formal education for nurses was the Civil War. Prior to the Civil War, most women only provided nursing care in the home to their family. Every woman expected to nurse family members. Older women, who had extensive family experience and needed to earn a living, would care for neighbors or contacts that were referred by word of mouth (Reverby, 1987). As women began to care for the soldiers during the war, they transferred their skills and knowledge from home to the battlefield. The value of nursing care in the soldiers’ recovery and the need for formal education for nurses were both recognized as the Civil War came to a close.

The New England Hospital for Women and Children, located in Boston, was the first American school to offer nursing courses based on Nightingale’s guidelines. Opened in 1872, the school offered a formal training program with a 1-year curriculum similar to the one Nightingale developed at St. Thomas Hospital School of Nursing. In addition to 12 hours of required lectures, students were taught to take vital signs and apply bandages. Interestingly, students were not allowed to know the names of medications given to patients and the medication bottles were labeled by numbers. In 1875, the curriculum was extended to 16 months (Davis, 1991). Linda Richards, considered to be America’s first trained nurse, entered this school on the first day it opened and Mary Mahoney, the first African American nurse, was a graduate of the school (Davis, 1991).

In 1873, three more schools were opened that were supposedly patterned on the Nightingale model. The Bellevue Training School opened in New York City, the Connecticut Training School opened in Hartford, and Boston, Massachusetts was the site of the Boston Training School. These schools proposed to offer a desirable occupation for self-supporting women and provide good private nurses for the community (Kelly & Joel, 1996).

By the beginning of the 20th century, over 2,000 training schools had been opened. With few exceptions, Nightingale’s principles of education and curriculum were ignored. Curricula focused on character traits and habits and school priorities were “service first, education second” (nursingeducationhistory.org, 2012). The 3-year program of most nursing schools consisted primarily of on-the-job 7training, courses taught by physicians, and long hours of clinical practice. Students, known as “pupils,” provided nursing service for the hospital. In return, they received diplomas and pins at the completion of their training. Students entered the programs one by one as they were available and their services were needed. The patients were mostly poor, without families and/or homes to provide care. From the institution’s standpoint, graduates were a byproduct rather than a purpose for the training school. “Trained nurses” generally gave private care in wealthy homes, oversaw pupils in a training school, or cared for the poor in their homes after graduation (Reverby, 1984).

If textbooks were available to students, they were primarily authored by physicians. The first nurse-authored text, A Text-Book for Nursing: For the Use of Training Schools, Families and Private Students, was written by Clara Weeks (later Weeks-Shaw), an 1880 graduate of the New York Hospital and founding superintendent of the Paterson General Hospital School (Obituary, 1940). The possession of such a text led to decreased dependence of graduates on their course notes, supplied information that would otherwise have been missed because of cancelled lectures or note-taking student exhaustion, reinforced the idea that nursing required more than fine character, and exerted a standardizing effect on training school expectations. The approximately 100 names in the comprehensive list of medicines, including ether, oxygen, topical agents, and multiple names for the same substance, subverted efforts to keep nurses ignorant of the names of medicines they were administering. By the third edition, Weeks-Shaw (1902) identified the primary audience as “professional” nurses rather than “amateurs” and assumed an elementary acquaintance with subjects such as anatomy and physiology, “which is now a fundamental part of training.”

Despite the founding of formalized education, the emergence of training schools and some public awareness of the need for “trained nurses,” the social climate of the late 1800s was not conducive to the advancement of women-centered issues. Society expected women to assume private, supportive roles rather than public, authoritative ones. The public perception of nursing was an extension of women’s supportive and caring role in the home. Even Nightingale advocated against professional status for nurses through opposition of credentialing (or licensure) of graduate nurses (Palmer, 1985). The dependence of nursing education on hospitals perpetuated the private, supportive role of women, and precluded them from participation in substantive decisions related to health care policy within and outside of institutions (Ruby, 1999).

DIVERSITY IN EARLY NURSING EDUCATION

Diverse Schools

Mary Mahoney, the first African American nurse, entered the New England Hospital for Women and Children School of Nursing on March 23, 1878. Her acceptance at this school was unique at a time in American society when the majority of educational institutions were not integrated (Davis, 1991). This lack of integration, however, did not deter African American women from entering 8the profession of nursing. In 1891, Provident Hospital in Chicago was founded, which was the first training school for Black nurses (Kelly & Joel, 1996).

Howard University Training School for Nurses was established in 1893 to train African American nurses to care for the many Blacks who settled in Washington, DC after the Civil War. The school transferred to Freedman’s Hospital in 1894 and by 1944 had 166 students (Washington, 2012). This rapid expansion was experienced by other African American nursing programs (Kalisch & Kalisch, 1978). Freedman’s Hospital School transferred to Howard University in 1967 and graduated its last class in 1973. Howard University School of Nursing has offered a baccalaureate degree since 1974 and initiated a master’s degree in nursing in 1980. After the Brown vs Board of Education decision in 1954, schools of nursing that served predominantly African American students began to decline and, by the late 1960s, nursing schools throughout the United States were fully integrated (Carnegie, 2005).

Sage Memorial Hospital School of Nursing opened in 1930 and was located in northeastern Arizona, at Ganado, 56 miles northwest of Gallup, New Mexico, in the heart of the Navajo Indian Reservation. It was part of Sage Memorial Hospital, built by the National Missions of the Presbyterian Church, which provided care for Native Americans (Kalisch & Kalisch, 1978).

The school of nursing operated through 1953; it was the only nursing school established for the sole purpose of training Native American women to be nurses. By 1943, students enrolled in the school came from widely diverse backgrounds including Native American, Hispanic, Hawaiian, Cuban, and Japanese. In the 1930s and 1940s, such training and cultural exchange among minority women was not found anywhere else in the United States. Students developed a camaraderie and commitment, while they completed coursework and tended the hospital floors 8 hours a day, 6 days a week (Pollitt, Streeter, & Walsh, 2011).

Men in Nursing Education

One little known legacy of the Civil War is the inclusion of men in nursing. Walt Whitman, known for his poetry, was a nurse in the Civil War. He cared for wounded soldiers in Washington, DC for 5 years and was an early practitioner of holistic nursing incorporating active listening, therapeutic touch, and the instillation of hope in patients (Ahrens, 2002).

There were, however, few nursing schools in the late 19th century that accommodated men; a few schools provided an abbreviated curriculum that trained men as “attendants.” The McLean Asylum School of Nursing in Massachusetts was among the first to provide nursing education for men. Established in 1882, the 2-year curriculum prepared graduates to work in the mental health facilities of the time. Treatments in those facilities included application of restraints (such as strait jackets) and “tubbing” (placing the patient in a bathtub with a wooden cover locked onto the tub so only the patient’s head was exposed) and it was believed the tubs required the physical power men possessed (Kenny, 2008).

The first true formal school of nursing for men was established at Bellevue Hospital in New York City in 1888 by Darius Mills. One of the best-known schools 9of nursing for men was the Alexian Brothers Hospital School of Nursing. It opened in 1898 and was the last of its kind to close in 1969 (LaRocco, 2011). Although the school admitted only religious brothers for most of its early history, in 1927 it began to accept lay students. In 1939, the school began an affiliation with DePaul University so students could take biology and other science courses to apply toward bachelor’s degrees. By 1955, the school had obtained full National League for Nursing (NLN) accreditation and by 1962, 13 full-time faculty members and eight lecturers educated a graduating class of 42 students. This was the largest class in the school’s history and one of the largest classes in any men’s nursing school in the country (Wall, 2009). By the mid-1960s, men were being admitted to most hospital nursing programs and the school graduated its last class in 1969. In addition, by the 1960s, the ANA was encouraging prospective nurses to earn their baccalaureates in university nursing programs.

Reports and Standards of the Late 19th and Early 20th Centuries

The International Congress of Charities, Correction and Philanthropy met in Chicago as part of the Columbian Exposition of 1893. Isabel Hampton, the founding principal of the Training School and Superintendent of Nurses at Johns Hopkins Hospital, played a leading role in planning the nursing sessions for the Congress. At a plenary session, she presented a paper, “Educational Standards for Nurses,” which argued that hospitals had a responsibility to provide actual education for nursing students; the paper also urged superintendents to work together to establish educational standards (James, 2002). At this time, curricula, standards for admission, and requirements for graduation varied dramatically among schools. Attempts at standardization had begun but were not common.

Hampton’s paper included her proposal to extend the training period to 3 years in order to allow the shortening of the “practical training” to 8 hours per day. She also recommended admission of students with “stated times for entrance into the school, and the teaching year … divided according to the academic terms usually adopted in our public schools and colleges” (Robb, 1907). During the week of the Congress, Hampton instigated an informal meeting of nursing superintendents that laid the groundwork for the formation of the American Society of Superintendents of Training Schools (ASSTS) in the United States and Canada, which later, in 1912, was renamed the National League of Nursing Education (NLNE). Certainly a landmark event within nursing, this was also the first association of a professional nature organized and controlled by women (Bullough & Bullough, 1978).

The year 1893 marked the publication of Hampton’s Nursing: Its Principles and Practice for Hospital and Private Use. The first 25 pages are devoted to a description of a training school, including physical facilities, contents of a reference library, a 2-year curriculum plan for both didactic content and planned, regular clinical rotations, and examinations. Hampton notably omitted reference to the pupil nurse residence as a character-training instrument in the training school system, though she noted the importance of the residence for the health and social development of students (Dodd, 2001). Clearly, she was pushing for a progressive professional education and a professional identity for nursing.

10In 1912, the ASSTS became the NLNE and their objectives were to continue to develop and work for a uniform curriculum. In 1915, Adelaide Nutting commented on the educational status of nursing and the NLNE presented a standard curriculum for schools of nursing. The curriculum was divided into seven areas, each of which contained two or more courses. The total program of study was delineated including the general length, vacation time, daily hours of work, and the general scheme of practical work for 36 months of the program. There was a strong emphasis on student activity including observation, accurate recording, participation in actual dissection, experimentation, and giving of patient care (Bacon, 1987).

In 1925, the Committee on the Grading of Nursing Schools was formed. The function of the Committee was to study the ways and means for ensuring an ample supply of nursing service of whatever type and quality are needed for adequate care of the patients at a price within its reach. The Grading Committee worked from 1926 to 1934 to produce “gradings” based on answers to survey forms. Each school received individualized feedback about its own characteristics in comparison to all other participating schools (Committee on the Grading of Nursing Schools, 1931). The NLNE’s 1927 A Curriculum for Schools of Nursing provided the implicit framework for the surveys and reports. Although the original hope was that the Committee would rank schools into A, B, and C categories as the Flexner report had, the Committee pointed out that the work and cost of visiting the many nursing schools (as compared to Flexner’s 155) made this impossible.

Even without this actual “grading,” it provided more data than nursing ever had about its schools. For example, it found that the median U.S. nursing school had 10 faculty members: the superintendent of the hospital, the superintendent of nurses, the night supervisor, the day supervisor, two heads of special departments—usually operating room and delivery room, one assistant in a special department, two other head nurses, and one instructor. This median varied by region from four to 17 faculty members. Forty-two percent of the faculty had not completed high school. Forty-five percent of the superintendents of nursing came to their positions more recently than the senior students’ admission dates. Hospital schools in the inter-world-war period presented a highly variable picture. Some still offered only apprenticeship learning, but without “master craftswoman” nurses and with a social milieu more consonant with turn-of-the-century culture. This gave nursing a backward, rigid quality that was susceptible to caricature. Others were pushing their limits to provide stimulating learning and an environment more akin to other educational institutions (Egenes, 1998).

In 1917, 1927, and 1937, the NLNE published a series of curriculum recommendations in book form. The reaction to the title of the first, Standard Curriculum …, led to naming the second A Curriculum … and the third A Curriculum Guide…. The first was developed by a relatively small group, but the second and third involved a long process with broad input, which, even apart from the product, served an important function. The published curricula were intended to reflect a generalization about what the better schools were doing or aimed to accomplish. As such they give a picture of change over the 20-year period, but cannot be regarded as providing a snapshot of a typical school. Each volume represents substantial change from the previous, and where the same course topical area exists in all three, the level of detail 11and specificity increases with each decade. Indeed, the markedly increased length and wordy style of the 1937 volume appropriately carries the title “Guide.” Each Curriculum book increased the number of classroom hours and decreased the recommended hours of patient care, in effect making nursing service more expensive. Each Curriculum also increased the pre-requisite educational level: 4 years of high school (temporary tolerance of 2 years in 1917), 4 years of high school in 1927, and 1 to 2 years of college or normal school in addition to high school by 1937 (National League of Nursing Education, 1917, 1927, 1937). This was a selective standard, which was more easily met by students from urban homes. In 1920, only 16.8% of the age cohort graduated from high school; in 1930, 20%; and in 1940, 50.8% graduated (Tyack, 1974). It was not until the 1930s, with the depressed labor market and enforcement of child labor and mandatory attendance laws, that one-third of the age cohort nationally attended high school. With the beginnings of a nursing school accreditation mechanism before World War II and the post-war National Nursing Accrediting Service (NNAS), the function that the Curriculum books were intended to serve was now incarnated by consultants and supplanted by concise written standards (Committee of the Six National Nursing Organizations on Unification of Accrediting Services, 1949).

In 1951, the 42-year-old National Association of Colored Graduate Nurses merged with the ANA. The ANA took on new responsibilities through its Intergroup Relations Program, which was aimed at removing the remaining membership barriers in certain district and state associations (Kalisch & Kalisch, 1978).

THE 20TH CENTURY

Nursing Education Through Two World Wars

World War I

When the United States entered World War I, the need for nurses during national emergencies became clear. Admissions to nursing schools during 1917 and 1918 increased by about 25% (Bacon, 1987). The two phenomena that impacted nursing education during World War I were the development of the Vassar Training Camp and the founding of the Army School of Nursing.

The Vassar Training Camp for Nurses was established in 1918. Its purpose was to enroll female college graduates in a 3-month intensive course that addressed natural and social sciences and fundamental nursing skills. This 3-month intensive course replaced the first year of nursing school; following this course, students completed the final 2 years of school in one of 35 selected schools of nursing (Bacon, 1987). Of the 439 college graduates who entered the Vassar Camp, 418 completed the course, went on to nursing school, replaced nurses who had entered the armed services, and helped fill key leadership roles in nursing for the next several decades (Kalisch & Kalisch, 1978). Although short-lived, the Vassar Training Camp provided the opportunity to build nursing competencies on a college education foundation and contributed to the eventual move of nursing education into the university setting (Bacon, 1987).

12In 1918, Annie W. Goodrich, president of the ANA, proposed the development of an Army School of Nursing. This was in response to extremely vocal groups who believed that, because of the war, the education preparation of nurses should be shortened. With the backing of the NLNE and the ANA in addition to nurse leaders such as Frances Payne Bolton, the Secretary of War approved the school and Annie Goodrich became its first dean. She developed the curriculum according to the Standard Curriculum for Schools of Nursing published by the NLNE in 1917 (Kalisch & Kalisch, 1978). The response to the Army School of Nursing was overwhelmingly positive and many more women applied than could be accepted.

World War II and the Cadet Nurse Corps

World War II, with its demands for all able-bodied young men for military service, mobilized available women for employment or volunteer service. Indeed, every resident was engaged in the effort by the mandates of food, clothing, and gasoline rationing, and by persuasion toward everything from tending victory gardens to buying savings bonds. From mid-1941 to mid-1943, with the help of federal aid, nursing schools increased their enrollments by 13,000 over the baseline year and 4,000 post-diploma nurses completed post–basic course work to enable them to fill the places of nurses who enlisted. Some inactive nurses returned to practice (Roberts, 1954). Despite the effort necessary to bring about this increase, hospitals were floundering and more nurses were needed for the military services.

Congress passed the Bolton Act, which authorized the complex of activities known as the Cadet Nurse Corps (CNC) in June 1943. It was conceived as a mechanism to avoid civilian hospital collapse, to provide nursing to the military, and to ensure an adequate education for student nurse cadets. The goal was to recruit 65,000 high school graduates into nursing schools in the first year (1943–1944) and 60,000 the next year. This represented 10% of girls graduating from high school and the whole percentage of those who would expect to go to college! The program exceeded the goals for both years (Kalisch & Kalisch, 1978).

Hospitals sponsoring training schools recognized that CNC schools would out-recruit non-CNC schools, thereby almost certainly guaranteeing their closure or radical shrinkage. Thus, they signed on, despite the fact that hospitals had to establish a separate accounting for school costs, literally meet the requirements of their state boards of nurse examiners to the satisfaction of the CNC consultants, and allow their students to leave for federal service during the last 6 months of their programs, when they would otherwise be most valuable to their home schools. Schools received partial funding from a separate appropriation for the modifications necessary to build classrooms and library space, and to secure additional student housing. Visiting consultants looked at faculty numbers and qualifications, clinical facilities available for learning, curricula, hours of student clinical and class work, the school’s ability to accelerate course work to fit into 30 months, and the optimal number of students the school could accommodate (Robinson & Perry, 2001). Only high school graduates could qualify to become cadets (Petry, 1943). Schools were pressed to increase the size of their classes and number of classes admitted per year, to use local colleges for basic sciences to conserve nurse instructor time, and to develop affiliations with psychiatric hospitals, for 13educational reasons, and secondarily to free up dormitory space for more students to be admitted. Consultants could give 3-, 6-, or 12-month conditional approval to the schools while deficiencies were corrected (Robinson & Perry, 2001). Given the pressure to keep CNC-approved status, schools made painful changes.

Students, who were estimated to be providing 80% of care in civilian hospitals, experienced a changed practice context. They now had to decide what they could safely delegate to Red Cross volunteers and any paid aides available. Extra responsibility for nursing arose from the shortage of physicians. With grossly short staffing, nurses had to set priorities carefully. All of these circumstances altered student learning. The intense work of the consultants, who provided interpretation and linkage between the U.S. Public Health Service (USPHS) in Washington and each school, and their strategy of simultaneously naming deficiencies and identifying improvement goals, was a critical factor in the success of the programs as well as improvement in nursing education. Without the financial resources of the federal government to defray student costs, to assist with certain costs to schools, and to provide the consultation, auditing, and public relations/recruitment functions, the goals could not be met. Lucile Petry, the director of the Division of Nursing Education in the USPHS, combined a sense of the social significance of nursing with first-hand experience in nursing education, a humility that equipped her to work with all kinds of people, and generously give credit to everyone involved in the massive undertaking. Opinions differed on such questions as the cut-off point for irredeemably weak schools, but overall, the effort was pronounced a substantial success for nursing (Roberts, 1954).

The Remainder of the 20th Century

The nursing profession used the Depression years for major stock-taking and self-examination. For the first time registered nurses were available in hospitals for direct bedside care; patient care responsibility did not have to rest on students. Teachers and directors of nursing began to see the possibility of selecting patient care experiences for the student in relation to learning needs rather than to meet hospital service needs (Bacon, 1987). Increased expectations for cognitive learning by students were brought about by factors, which included hospital architecture, physician expectations, nursing efforts, and general culture change. With increased numbers of applicants during the Depression, schools were able to select capable students and grant diplomas that signified both cognitive learning and character.

By the 1940s, people routinely came to hospitals for care. In addition, patients who had formerly hired private nurses to care for them in the hospital were now admitted to wards, which were rooms that contained four to ten beds. Students were admitted as cohorts and attrition was hard to predict; the increased patient census made it necessary to hire graduate nurses (Vogel, 1980). These graduate nurses were often unemployed private duty nurses.

Experiments involving the housing of nursing programs in junior or community colleges were underway in the 1950s. Even the hospital-sponsored diploma programs, which decreased in numbers during the last part of the 20th century, were transformed into educationally focused efforts.

14The development of coronary care and intensive care units in the 1960s required nurses to develop critical thinking and clinical reasoning skills and take action in a wider range of clinical situations than had formerly been within nursing’s scope of practice. Educators were trying to sort out the implications for both undergraduate and graduate programs. Educators made decisions to focus on graduate preparation in nursing and by the 1960s, master’s programs were beginning to prepare clinical nurse specialists and nurse practitioner roles were being described in the literature.

During the 1960s, there was vigorous debate about educational preparation for nurses. In May 1965, the NLN passed a resolution that supported college-based nursing programs. In January of 1966, the ANA released a position paper that recommended baccalaureate preparation for professional nurses and associate degree education for technical nurses. These two documents were seen by many as one of the highest peaks in the profession’s history, one that reflected nursing’s strength and unity. Sadly, conflict within the NLN and ANA and public opposition to college-based nursing programs (voiced primarily by nurses who graduated from diploma schools) doomed the premise that professional nurses required baccalaureate education (Fondiller, 1999).

The Evolution of Current Educational Paths of Nursing

Starting in the early 1900s, universities began to enfold disciplines such as education, business administration, and engineering, which had originally been taught in freestanding, single-purpose institutions (Veysey, 1965). By the interwar period, the university became the dominant institution for postsecondary education (Graham, 1978). From 1920 to 1940, the percentage of women attending college in the 18- to 21-year-old cohort rose from 7.6% to 12.2%. Men’s college-going rates rose faster, so that the percentage of women in the student body dropped from 43% in 1920 to 40.2% in 1940 (Eisenmann, 2000; Solomon, 1985).

Nursing made overtures to a few colleges and universities prior to World War I. In 1899, the ASSTS developed the Hospital Economics course for nurses who had potential as superintendents of hospital and training schools. The program involved 8 months of study, using many courses existing in the Domestic Science department, but with a custom-designed course on teaching, and a Hospital Economics course that would be taught by nurses (Robb, 1907). This relationship with Teachers College grew and was cemented by the endowment in 1910 of a Chair in Nursing, occupied for many years by M. Adelaide Nutting. The nursing faculty at Teachers College continued to be influential in nursing education through the 1950s, as other educational centers began to share influence.

In the first decade of the 1900s, technical institutes such as Drexel in Philadelphia, Pratt in Brooklyn, and Mechanics in Rochester as well as Simmons College in Boston and Northwestern University in Chicago offered course work to nursing students (Robb, 1907). The designers of the 1917 Standard Curriculum … gave some thought to the relationship of nursing education to the collegiate system. They suggested that the theoretical work in a nursing school was equivalent to 36 units, or about 1 year of college, and the clinical work another 51 units.

15Few voices actively campaigned for the alignment of nursing education with institutions of higher learning even as late as the 1930s, despite the recommendation of the Rockefeller-funded Goldmark (1923) report, Nursing and Nursing Education in the United States, in the early 1920s. Initially, education at the university level was envisioned solely for the leaders of training schools.

Educators who wanted a university context for nursing, concentration on educational goals, and emancipation from dependence on the hospitals’ student work–study schemes, looked hopefully at the Yale University School of Nursing, funded by the Rockefeller Foundation starting in 1924, and headed by the determined and respected Annie W. Goodrich. Similarly encouraging was the program at Case Western Reserve University, endowed by Francis Payne Bolton in 1923, following considerable prior work within the Cleveland civic community. Vanderbilt was endowed by a combination of Rockefeller, Carnegie, and Commonwealth funds in 1930. The University of Chicago established a school of nursing in 1925 with an endowment from the distinguished but discontinued Illinois Training School (Hanson, 1991). Dillard University established a school in 1942 with substantial foundation support and governmental war-related funds. Mary Tennant, nursing adviser in the Rockefeller Foundation, pronounced the Dillard Division of Nursing “one of the most interesting developments in nursing education in the country” (Hine, 1989). Although these were milestone events, endowments did little to dissipate the caution, if not hostility, toward women on American campuses. Neither did they cure all that was ailing in nursing education. They funded significant program changes, but even these would not meet the accreditation standards of later decades (Faddis, 1973; Kalisch & Kalisch, 1978; Sheahan, 1980).

According to the Journal of the American Medical Association (JAMA), 25 universities granted bachelor’s degrees to nurses by 1926 (JAMA, 1927). By the end of the 1930s a bewildering array of “collegiate” programs existed, partly because baccalaureate programs were being invented by trial and error within the combinations of opportunities and constraints presented in each local hospital and university pair (Petry, 1937).

BACCALAUREATE EDUCATION

The diverse baccalaureate curricula of the 1930s multiplied by the 1950s. As one educator wrote in 1954, “Baccalaureate programs still seem to be in the experimental stage. They vary in purpose, structure, subject matter content, admission requirements, matriculation requirements, and degrees granted upon their completion. Some schools offering baccalaureate programs still aim to prepare nurses for specialized positions. Others, advancing from this traditional concept, seek to prepare graduates for generalized nursing in beginning positions” (Harms, 1954).

Although a few programs threaded general education and basic science courses through 5 years of study, the majority structured their programs with 2 years of college courses before or after the 3 years of nursing preparation, or book-ended the nursing years with the split 2 years of college work (Bridgman, 1949). Margaret Bridgman, an educator from Skidmore College who consulted with a large number of nursing schools, made favorable reference to the “upper division 16nursing major” in her volume directed toward both college and nursing educators (Bridgman, 1953). However, the paramount issues, she said, were whether or not (1) the academic institution and academic goals had meaningful involvement and influence in the program as a whole, and (2) degree-goal and diploma-goal students were co-mingled in nursing courses. Programs that failed the first test criterion were termed the “affiliated” type. In 1950, 129 of 195 schools offering a basic (pre-licensure) program were of the affiliated type. In 1953, 104 of the 199 schools still offered both degree and diploma programs (Harms, 1954) and probably co-mingled the two types of students in courses. To further complicate the situation, only 9,000 of the 21,000 baccalaureate students in 1950 were pre-licensure students. The remaining 12,000 postdiploma baccalaureate students were not evenly distributed among schools, so some programs found themselves with a sprinkling of pre-licensure students among a class of experienced diploma graduates.

Bridgman recommended that postdiploma students be evaluated individually and provisionally with a tentative grant of credit based on prior learning, including nursing schoolwork, and successful completion of a term of academic work. The student’s program would be made up of “deficiencies” in general education and prerequisite courses and then courses in the major itself. Credit-granting practices varied considerably from place to place, so a nurse could easily spend 1½ to 3 years earning the baccalaureate (Bridgman, 1953). Bridgman provided “suggestions for content” using the categories of:

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