Advantages of Re-Establishing Hospital Based Schools of Nursing

A Final Paper Proposal                                                                                                   Presented to the Faculty of School of Health Administration
Kennedy-Western University

In Partial Fulfillment for the Degree of 
Bachelor of HealthCare Administration

		                         By
                          Susan F. Dahl, MSN, CRNFA
                                   Seattle, Washington

                                
Advantages of Re-Establishing Hospital-Based Schools of Nursing
Abstract
	This study examined perceptions of hospital-based nursing schools among nursing professionals to determine whether this type of nursing education model is viable in the modern nursing context. Nursing education is faced with the twin problems of insufficient nurses, which creates a demand for rapid education of nurses, and ensuring adequate clinical quality of nurses, which creates a demand for more extensive undergraduate clinical training. Hospital-based nursing schools are three-year programs that provide more intensive clinical training than the two-year university-based programs. The study developed and disseminated a questionnaire to assess the perception of nursing professionals and nursing students on the issues related to hospital-based nursing schools including clinical quality and the shortage of nurses. Secondary research was conducted based on the available literature regarding nursing education and the historical development of the current nursing educational system. The study found that there was a generally favorable opinion of hospital-based nursing schools among the surveyed population, particularly in the area of the level of clinical training received at these types of schools. The study also found that there were significant attitudinal and financial barriers to increasing the number of hospital based nursing schools. The findings of this study are exploratory in nature and serve to define the problems and alternatives associated with nursing education and hospital-based nursing schools.

TABLE OF CONTENTS

CHAPTER 1
INTRODUCTION………………………………………………………………….1
Statement of the Problem………………………………………………………..1
Purpose of the Study……………………………………………………………...6
Importance of the Study…………………………………………………………..8
Scope of the Study………………………………………………………………..10
Rational of Study …………………………………………………………………10
Definition of Terms………………………………………………………………..11
Overview of the Study…………………………………………………………….12
CHAPTER 2
REVIEW OF LITERATURE……………………………………………………..13
Introduction………………………………………………………………………..13
Nursing Shortages and Nursing Education…………………………………….18
Trends in Nursing Education…………………………………………………….27
CHAPTER 3
METHODOLOGY…………………………………………………………………33
Approach…………………………………………………………………………..33
Data Gathering Method………………………………………………………….37
Database of the Study……………………………………………………………38
Validity of the Data………………………………………………………………..39
Originality and Limitations of the Study…………………………………………40
Summary of Chapter 3……………………………………………………………42
CHAPTER 4
DATA    ANALYSIS……………………………………………...……………….43
Primary Data
	Table 1……………………………………………………………………..43
	Table 2……………………………………………………………………..44
	Table 3………………………………………………………………..……44
	Table 4……………………………………………………………………..45
	Table 5……………………………………………………………………..46
	Table 6……………………………………………………………………..48
	Table 7…………………………………………………..…………………49
	Table 8………………………………………………………………….50-51
	Table 9………………………………………………………………….51-52
	Table 10………………………………………………………………..52-53
	Table 11……………………………………………………………………54
	Table 12……………………………………………………………….…55
	Table 13………………………………………………………………….56
Secondary Data…………………………………………………………………57
CHAPTER 5
SUMMARY, CONCLUSIONS, RECOMMENDATIONS…………………….64
Summary…………………………………………………………………………64
Conclusions……………………………………………………………………...66
Recommendations………………………………………………………………77
REFERENCES…………………………………………………………………..79
APPENDIX A…………………………………………………………………….83

Advantages of Re-Establishing Hospital-Based Schools of Nursing
Chapter 1
Introduction
Statement of the Problem
	Because education is a primary factor in achieving professional success, the quality of the degree has considerable importance. The use of teaching methods that omit critical aspects of the subject material can result in shortfalls in the knowledge base of the student. In addition, the use of educational techniques that have not been critically assessed for effectiveness can hamper the ability of graduates to apply their knowledge in the practical situations that are encountered in the workplace. As in other professions, the quality of nursing education has a direct impact on the ability of graduates to provide the level of patient care that conforms to the standards of the profession.
	Nursing curricula is currently structured to offer either a baccalaureate or an associate’s degree, both of which are sufficient qualifications for obtaining licensure as a Registered Nurse (RN). In both types of degree programs, the trend is towards weighting the educational experience toward the didactic components, with reduced emphasis on clinical training. As a result, the primary emphasis of the education is on academic knowledge that is obtained from readings, lectures and other types of media presentations. The current methods used to educate nurses represent a significant divergence from the traditional concept of nursing education that had a strong focus on clinical training. In this traditional model, the nursing school was associated with a hospital that provided the opportunity for practical applications of theoretical knowledge. While the nursing students were expected to acquire academic knowledge, they were also expected to demonstrate an understanding of the way that this knowledge can be used to provide patient care. While the numbers of hospital-based nursing schools have declined significantly, there are some that continue in operation. These institutions offer a Diploma in Nursing, which allows graduates to apply for licensure as a RN. Diploma nursing programs typically require 3 years of education, compared to 2 years for an Associates degree and 4 years for a baccalaureate Degree.
	The hospital-based concept of nursing education has declined in popularity for a number of reasons. The original nursing schools were essentially training schools that emphasized the tasks associated with nursing, but provided relatively little education in the sciences underlying nursing practice. The traditional model for nursing education was associated with the apprenticeship approach to medical training that was the dominant method of medical education until the early twentieth century. In addition, the demand for nurses had dramatically increased in the past several decades, which created the need to educate a larger number of nursing students in a shorter period of time. The hospital based method of nursing education requires a grater commitment from students than the modern academic approach due to the additional practical training, and can function as a disincentive for some students to enter a nursing curriculum. 
One of the primary difficulties in the current system of nursing education is need to train graduates from baccalaureate and associates programs after they have entered the workforce. Currently, there is an insufficient number of openings for students in nursing school, which is largely due to a shortage of nursing educators (Jessak, 2005). This situation results in a waiting list for candidates to nursing school. During the waiting period, aspiring students are encouraged to continue taking didactic courses in the sciences to improve their position in the selection process for future placement in the nursing school. Once the student enters a baccalaureate or associates program, the primary emphasis of studies is on nursing theory. This type of educational model is related to the shortage of nursing educators, and enables a small number of instructors to provide education to a large number of students. As a result, there are insufficient resources to provide clinical training. The graduates of these programs are qualified to take and pass the licensure examination to become an RN, which focuses heavily on the theoretical and academic aspects of nursing. Nonetheless, they do not have sufficient clinical training. As a result, they undergo a de-facto internship in the clinical setting that can take as long as two years depending on the type of specialty that a nursing school graduate selects.
The training involves the practical applications of the academic knowledge obtained during their educational experience and resembles the type of practical education that is part of the curriculum in hospital-based nursing schools. As a result of the need for additional training in the clinical setting, a significant amount of time elapses before the nursing graduates become fully productive and safe caregivers for the healthcare consumer.
	At the current time, there is significant shortage of nurses in the United States as well as in other industrialized nations (Takase, Maude & Manias, 2005). There are a large number of factors that contribute to the shortage such as low enrollment in nursing schools and a high rate of attrition due to nurse “burn-out.” The lack of qualified nurses has a significant impact on the quality of healthcare, with some institutions employing unlicensed assistive personnel (UAP) to provide basic patient care. The lack of qualified nurses also has an indirect impact on accessibility by limiting the ability of the healthcare system to deliver services to a wide population. In addition, the shortage of nurses tends to increase the cost of healthcare with institutions willing to offer higher wages to attract and retain nurses. The use of unlicensed staff can also increase risks for the institution and the costs associated with risk management.
Periods of shortage and periods of excess supply of RNs have occurred regularly in the United States, with various explanations offered regarding the cause of the phenomenon (Friss, 1994). The cause of the cycle of shortage and excess may be due to a lack of increase in wages over time, with the lower wages functioning as a disincentive to enter the profession. The shortage stimulates and increases in wages, which results in excess supply (Yett, 1975). Because of the current high level of wages for nurses, this explanation for the shortage of nurses is likely to be incorrect. The cause of the cycle may also be attributable to shifting levels of job satisfaction, with low job satisfaction prompting nurses to leave the profession. The resulting shortages lead to an improvement in working conditions and job satisfaction, which results in an excess supply (Johnston, 1997; Takase, Maude & Manias, 2005). Another potential cause of the cycle is the restructuring the healthcare system to achieve cost savings, which results in a reduction in the number of nurses and an increase in the expected levels of productivity for nurses (Shogren, Calkins & Wilburn, 1996). There have also been suggestions that the shortage of nursing occurs only in critical specialty areas that require more education and training, which creates the appearance of a universal shortage in the profession (Dracup & Bryan-Brown, 1998). There are also indications that the nursing shortage is most severe in rural locations, which is attributed to the lower wages paid in rural healthcare system and the desire to live in a more urbanized environment. The previous investigations of the causes of the shortage of nurses have not examined the relationship between the type of educational methods used in nursing and the desire to enter and remain in the profession. 
Purpose of the Study
	The purpose of this study is to investigate the advantages of hospital-based nursing education as a potential remedy for the problems of the shortage of nursing, reducing nursing costs, reducing patient and institutional risk, and increasing the quality of patient care through improvements in clinical judgment. In the past half-century, the nursing profession has reorganized its educational curricula to emphasize the theoretical and practical aspects of nursing while reducing the clinical training component. There has been insufficient investigation of the impact that this transition has had on the profession. There has also been insufficient examination of the possibility of reviving the hospital-based educational model that combines the theoretical and practical aspects of the curriculum. The secondary purpose of this study is to determine if there is a need to revive hospital-based nursing education. Because of the current structure of the nursing educational system and the resistance to change that exists in the system, the expanded use of hospital-based nursing education requires the development of clear and convincing evidence that the approach is superior and can provide a significant benefit for the profession. 
	This study answers the following research questions:
1.	What are the advantages for nursing students at hospital-based nursing schools?
2.	What are the advantages for the nursing profession from hospital-based nursing schools?
3.	What are the disadvantages of hospital-based nursing schools for students and for the profession?
4.	What are the barriers inhibiting the expanded use of hospital-based nursing schools?
5.	Are there any current efforts to promote hospital-based nursing schools?
6.	What is the position of proponents of degree-based programs regarding hospital-based nursing schools?
	This study proceeds from the perspective of the alternative hypothesis that hospital-based nursing schools provide a significant advantage for the nursing profession when compared to degree-based programs. The theoretical assumption underlying the study is that effective nursing requires a thorough understanding of both the theoretical and the practical application of theory in clinical settings. The practical aspects of the profession can only be learned in the clinical setting, with the practical training currently occurring following graduation and licensure. A more effective approach would be to include the practical training as part of the undergraduate educational process to insure that all graduates of nursing educational programs have met a minimum standard for clinical practice.
Importance of the Study
	The findings of this study have significant implications for the nursing profession by identifying potential methods to change the existing methods of educating nurses. The hospital-based approach to nursing education can potentially lower costs for the profession by reducing the need to instruct newly graduated and licensed nurses in clinical practice, with these costs borne by the institutions employing these nurses. The hospital-based approach also has the potential to improve the overall quality of nursing by providing clinical training in a structured and orderly manner. There is also the possibility that the hospital-based approach to education can increase accessibility to healthcare for the general public by providing a larger number of nurses with clinical skills at the time of their graduation. The hospital-based approach can also have an impact on the shortage of nurses by allowing the nursing staff at the hospitals associated with the education to function as faculty. This would reduce the impact of the current constraint in nursing education due to insufficient faculty to meet the student demand for placement in nursing schools.
	This study also has importance for perspective nursing students by identifying the advantages and disadvantages of hospital-based nursing education. Because of the strong clinical focus of the hospital-based approach, nursing school candidates may be influenced to seek this type of educational experience rather than a degree-based program. Educational institutions are responsive to the demand created by students, which raises the possibility that an increased demand for hospital-based educational programs could lead to their general revival.
	The study has additional importance for future investigations of the topic of the optimal means to provide nursing education. It lays the foundation for studies regarding the effectiveness of the hospital-based educational approach for creating higher-level competencies among graduate nurses. In addition, it broadens the general base of knowledge regarding potential solutions for some of the problems such as the shortage of nurses that impact the profession.
Scope of the Study
	The scope of this study is limited to an examination of the advantages and disadvantages of hospital-based nursing education. The limitations of the scope of the study preclude a statistical comparison between hospital-based nursing education and degree-based programs that do not have a strong clinical component. Nonetheless, the scope of the study includes a descriptive approach to the issue of a comparison between the two educational models based on primary and secondary research. The scope of the study is further limited to the perceptions and opinions of practicing nurses, nursing educational faculty at educational institutions, nursing students, nursing administrators and physicians. The geographic scope of the study is limited to nursing professionals and students in a single urban area that offers a diversity of nursing practice and educational settings.
Rationale of the Study
	The fundamental rationale for the study is to determine whether the expanded use of the hospital-based model for nursing education can reduce costs, improve risk management and improve quality across the entire healthcare spectrum.  The research questions for this study were developed from a review of related literature, which indicated that the issues regarding the value of hospital-based nursing schools have not been extensively investigated. Because of the limited amount of research into the issue, it is necessary to gather preliminary data regarding the perceptions of nursing professionals towards hospital-based nursing schools. The research design used in this study is intended to provide this data as a means of determining the viability of the hospital-based schools of nursing in the modern healthcare environment. 
Definition of Terms
Associate Degree Nurse- a nurse that has been educated in a two-year program providing limited clinical training, with many of the basic science components completed prior to program admission.  
Baccalaureate Degree Nurse- a nurse educated in a four-year program providing limited clinical training, with the basic theoretical and science components completed during the course of study. 
Diploma Nurse- a nurse that has been educated in a hospital-based educational institution. 
Hospital-based Schools of Nursing- A nursing education program that offers a substantial practical educational component in an acute care setting, with basic theoretical and scientific classroom studies completed before and during the actual nursing program.  
National Council Licensure Examination-Registered Nurse (NCLEX-RN) - The licensure examination created by the National Council of State Boards of Nursing, which is a requirement for all nursing school graduates prior to practicing the profession of nursing as a RN.
Overview of the Study
	This study focuses on determining the advantages and disadvantages of hospital based nursing schools based on the perceptions of nursing professionals. Chapter 2 consists of a review of related literature that includes examinations of the nature of nursing education, its critical components and the impact of nursing education on professional issues such as the shortage of nurses. Chapter 3 is a description of the methodology used in this study, with is quantitative research based on the use of survey questionnaires that support the development of descriptive statistics. Chapter 4 presents the findings of the study based on the dissemination of the survey questionnaire. It also includes the perspectives regarding hospital-based nursing schools identified in the literature and related to the data produced by the survey questionnaire. Chapter 5 is summary and conclusion, with the research questions answered on the basis of the data obtained from primary and secondary research. 

Chapter 2
Review of Related Literature
Introduction
	The literature regarding hospital-based nursing schools and related topics is largely qualitative in nature due to the absence of empirical investigations into the nature and outcomes of nursing education. The literature does provide some quantitative information, however, in the form of statistics and the results of various types of surveys. In addition, there has been some empirical investigation of the factors that contribute to clinical competency among nurses and other medical professionals. The literature can be broadly characterized into the history of the development of university-based nursing schools, the impact of nursing education on various professional issues such as the shortage of nurses and the general trends in nursing education at the current time. These categories establish the method for organizing the review of related literature.
Development of the University-Based Nursing Schools
	During the early nineteenth century, nursing education in the United States was conducted at hospitals and was not systematic (Donahue, 1996). In the majority of hospitals, new nurses were immediately placed on wards and functioned as apprentices for the more experienced nursing staff (Asubonteng, McCleary & Munchs, 1995). The need for nurses that developed during the Civil War brought the need to foster the development of appropriate educational methods to the attention of the government. At the same time, the Nightingale concept involving formal education for nurses was introduced into the United States from England. This led to the development of formal nurse training schools attached to larger hospitals, with the majority of these schools located in the eastern part of the United States. The first school of nursing was opened by Women’s Hospital in Philadelphia in 1861, which had the express purpose of training nurses. One of the factors that resulted in the continued linkage between the schools of nursing and the hospitals was the lack of endowment, with the nursing schools unable to financially function as educational institutions fully independent of the hospitals.
	The gradual transition towards the use of the university based degree approach to nursing education began in the early twentieth century. Because of the perceived need to educate graduate nurses to become instructors at the hospital-based nursing schools, a program was established to train nursing educators at Columbia University, Teachers College. This program was not intended to compete with the hospital-based nursing schools, but rather to train nursing faculty in related subjects such as hospital economics and educational methods (Donahue, 1996). The Teachers College gradually began fostering the concept of independent nursing schools operated by universities, largely due to the efforts of Mary Nutting who had been granted the first American professorship in nursing by Columbia University in 1907. This movement was due to the desire of the nursing profession to gain control over nursing standards and the educational process. In the hospital-based educational system, the hospital that provided the funding for the school dictated the quality of the training, which resulted in variability of standards. As a result, the development of university based nursing education was viewed as a means to sever the professions dependence on hospitals and to establish uniform standards for all nursing education. The movement towards university based nursing schools was supported by the ability of the profession to obtain legal controls to prevent the spread of poor quality schools such as the requirement for licensure and testing (Donahue, 1996). As a result of these efforts, the number of university-based schools of nursing grew dramatically in the first half of the twentieth century.
The transition from the traditional hospital-based schools of nursing towards the university-based approach gained momentum during World War II (Haase, 1990). In part, the development of the Associates degree approach to nursing was due to the shortage in qualified nurses that occurred during World War II, with an increased demand for nursing services to tend to the casualties from military operations. A more important factor for the development of university-based education was a reform movement within the nursing profession that desired to include nursing as a part of the general education system in the United States. Prior to this time, the majority of nursing education had taken place in hospital-based schools, which were often not affiliated with a university. As a result, there was a high degree of variability in the nature of nursing education due to the absence of a universally recognized set of standards. In addition, the hospital-based schools were widely regarded as training institutions that did not provide nurses with the same level of status as graduates from universities. The reform movement also envisioned new roles for nurses in administration and providing patient care through agencies that were not necessarily affiliated with hospitals. As a result, there was a perceived need to develop a curriculum that expanded the scope of nursing education to include the skills necessary to support these broader roles. From the perspective of the period, hospital-based nursing education was viewed as constraining nurses to practice solely in the hospital setting.
To a large degree, the transition from the hospital-based schools of nursing to schools associated with universities was prompted by the desire of the profession to gain greater status and recognition in the medical community (Lusk & Robertson, 2004). While physicians had a relatively high regard for nurses following the Civil War, this regard began to deteriorate as they became concerned about the professional aspirations of nurses. This concern was centered on the ability of nurses to make independent decisions regarding patient care, which physicians feared would undermine their position of authority in the medical profession. This resulted in physicians’ objecting to nursing education, which was viewed as the source of the independent decision-making capabilities among nurses. The American Medical Association was also generally opposed to licensure for nurses, which they believed would result in overly qualified nurses that would be unable to find sufficient employment. By the 1920s, the general trend was towards a smaller number of medical schools and a larger number of nursing schools. As a result, physicians continued to be generally opposed to university based nursing schools and attributed the increase in healthcare costs to the increased number of highly trained nurses. These criticisms increased the support for the movement towards university based nursing schools as a means of increasing the status of nursing in the medical community resulting the award of a degree that was testimony that the recipient had met a specified standard. By the 1960s, the transition to the university degree model for nursing education was largely complete, with only a relatively small number of hospital-based nursing schools remaining in existence. The hospital-based schools adopted the academic approach of the university-based educational model, although they retained a strong clinical component for the educational process.
Nursing Shortages and Nursing Education
	There is evidence that there is some connection between nursing shortages and the availability of trained faculty with advance degrees to staff nursing schools (Evans, 2005). In 2000, less than 1% of nursing school graduates held doctoral degrees and only 9% held master’s degrees. In 2004, 32,000 nursing school applicants were rejected although many of the applicants were qualified to attend nursing school. The high rejection rate was primarily due to a lack of sufficient positions in the schools to meet demand. In the university-based nursing school system, all faculty members are required to hold an advanced degree. This traditional policy in universities coupled with the shortage of nurses with advanced degrees creates an inherent constraint on the ability of nursing schools to expand their facilities to meet demand. In part, the shortage of faculty is due to the structure of the nursing profession. Newly graduated nurses are able to enter the profession and command relatively high salaries due to the shortage of nurses. Pursuing an advanced degree takes a great deal of time away from work, with the high salaries creating a disincentive. In addition, the salaries offered by educational institutions for faculty are often at a par or below the salaries that nurses can command in the workplace. Potential solutions to the issue involve a larger role for public funding of scholarships or other types of financial aid for nurses pursuing graduate work, and an increase in the salary that is offered to faculty members.
	The findings of a survey taken in the state of Florida reflects the general issues involved with staffing shortages in nursing education (Brunnel, 2005). The state had approximately 10,000 applicants for nursing schools, with an admission rate of only 41%. Even if all qualified applicants were admitted to nursing schools, there would remain a shortfall of approximately 23% of the projected nursing needs in the state. The vacancy rate for existing faculty positions in the state are 7% for schools offering Associates degrees and 11% for schools offering baccalaureate degrees. The survey also indicated that the primary barrier to expanding nursing educational programs was a shortage of qualified faculty members. This was followed in importance by insufficient funding to support faculty positions. The third greatest barrier to expanding nursing education was insufficient clinical sites to assist with the education of nurses. The survey also found that there were significant regional variations in the length of time necessary for nursing schools to recruit qualified faculty members. This can be attributed to the salaries offered by the schools to faculty as well as the desirability of the location where the schools are situated. Although this survey provides a general indication of the issues associated with nursing education in Florida, the sample size was relatively small and involved only 56 respondents. As a result, the findings of the survey may not be general, although the same conclusions are supported by other analysis of the available data (Evans 2005).
	A qualitative opinion offered by McNamara (2000), a director of a nursing workforce development project in the state of Arizona, suggests that the low retention rates in nursing are due to the absence of mentoring in professional work environments. The general cultural trend among newly graduate nurses is towards a greater level of workplace mobility in response to conditions, situations or events that they do not approve of. In effect, younger nurses are more likely to seek a new position or exit the profession if their job satisfaction expectations are not met. Despite this position calling for an increase in mentoring in the professional environment, the author is opposed to the concept of returning to the hospital-based educational model for nursing. The majority of nurses in Arizona are graduates of two-year Associates degree programs. The author contends that the applicant pools would prefer a more rapid and academic education to allow them to more rapidly enter the workforce. The primary emphasis of the existing educational structure is to encourage the Associate Degree nurses to take courses on a part-time basis to obtain a baccalaureate degree while they are working. This position is based on the dwindling number of applicants for the existing number of seats in nursing schools, although there are more applicants than positions. The author contends that the applicants would not prefer a hospital-based diploma program because of the additional time that it would involve before they could enter the workforce. The author also indicates that many of the nurses who do obtain post-graduate degrees do not enter academia because of the more lucrative opportunities available in the healthcare system.
	A critical assessment of the university-based approach to nursing education suggests that it has not evolved to meet the changing understanding of education and the way in which people acquire knowledge (Lindeman, 2000). The structure of many nursing education programs is based on paradigms that are rooted in the past, and use traditional techniques such as passive learning that are not suited to the modern educational environment. Nursing education in general is based on a layered concept in which there are different levels of knowledge and skills that are implicit in each degree level. In the actual practice setting, however, nurses are required to perform similar functions regardless of whether they entered the profession with an associates or a baccalaureate degree. The current approach to nursing education also does not recognize that students learn in different ways and does not provide the ability to adapt the learning experience in accordance with the students’ needs. As a result, there is variability in outcomes despite the standardization of the educational process. Despite these apparent shortcomings in the nursing education system, most nursing schools have a high rate of graduates passing the NCLEX-RN examinations. This suggests that the schools are teaching to the requirements of the examinations rather than to the needs of the profession. In part, this approach is due to the ability to use NCLEX-RN passing rates as an ostensible measure of the effectiveness of the nursing education program.
	There remains a general assumption in nursing education that the baccalaureate degree is necessary for nurses to obtain to achieve professional advancement (D’Antonio, 2004). As a result of this assumption, the associate degree is viewed as a means to enter the profession, but there is an implicit expectation that associate degree nurses will eventually complete their baccalaureate degree. In the current structure of the profession, the advanced practice nursing specialties require a master’s degree, with the baccalaureate degree as a prerequisite. Although this general pattern of continuing academic education provides advancement within the profession, only a relatively small percentage of nursing professionals follow the career path. A large number of nurses do not advance beyond the associates degree level, with the RN credential enabling them to command a relatively high salary without the need to engage in further academic education (McNamara, 2000).
	An empirical investigation examined the relationship between the clinical decision-making skills of nursing students and their experience and academic ability (Botti & Reeve, 2003). The study asked second-year and third-year student nurses in a baccalaureate-nursing program to perform a hypothetical clinical task that involved generating a hypothesis, to recognize evidence that did not support the hypothesis, to seek additional information and to diagnose accurately. The study group was of mixed academic ability; with both high and low scores in general academic ability and their performance in nursing school. The findings of the study indicated that general academic ability and nursing knowledge are independent of the ability of engage in the clinical practice of nursing. Test subjects with high academic ability and theoretical knowledge of nursing performed better than their peers in low-complexity tasks. As the tasks increased in complexity, there was no difference in the performance of the students. The conclusion of the study is that domain-specific knowledge in clinical practice is necessary to perform the more complex tasks associated with nursing care. The findings further suggest that a clinical education component should be strongly emphasized in the nursing curriculum due to the difficulties that students have in applying theoretical knowledge to practical clinical situations regardless of their level of academic ability.
	A study conducted regarding the effectiveness of clinical rotations among medical students determined that there was considerable variation in the quality of the educational experience (Daelmans et al, 2004). The system of medical education is increasingly defining its objectives in terms of competencies rather than in terms of academic learning goals. As a result, there is increased reliance on the use of clinical training as a means of obtaining the necessary competencies, which are supported by the theoretical aspects of academic learning. This study was intended to examine the effectiveness of the clinical setting as an environment that supported the acquisition of competencies for students. The research involved the dissemination of a questionnaire to students who had completed clinical rotations, with the data elicited by the questionnaire intended to assess the students’ perception of the experience. The findings of the study concluded that there was significant variability in the perceptions of the students regarding the usefulness of the rotation in providing them with clinical competencies. The authors attribute this variation to the way in which the clinical experience was structured for the students. In many cases, there was insufficient supervision and feedback, with the level decreasing as the seniority of the supervisor increased. The findings of this study provide information for the structuring of clinical education programs to insure that they are achieving their desired objective of increasing student competencies. In the context of this study, no distinction was made between clinical settings that were affiliated with the learning institution and those that were directly connected with the learning institution.
	A study that investigated the difference in the perception of medical student regarding community-based and hospital-based teaching methods found that there were relative advantages to both approaches (O’Sullivan, Martin and Murray, 2000). The research methodology involved the use of semi-structured interviews and focus groups involving students that had experienced both types of clinical teaching methods during their educational process. The sampling, however, was relatively small, consisting of only 24 interviewees and 18 participants in focus groups. The findings of the study indicated that the participants perceived the hospital-based clinical experience as essential for learning about acute conditions and the procedures that were necessary to deal with these conditions. The community-based clinical experience provided the opportunity to learn about the psychosocial aspects of medicine such as the need for communication skills and a greater awareness of patient autonomy. The findings also indicated that the students perceived both settings as relatively equal for the acquisition of fundamental clinical skills. While this study involves medical students, it nonetheless has applications to nursing education through its identification of the benefits of clinical experience as part of the learning process.
	An investigation of the shortage of perioperative nurses in the area around San Jose California established a tentative connection between the nursing shortage and the low percentage of schools of nursing that offer preceptor-ships or clinical internships in the perioperative practice setting (Ward & Saylor, 2002). The authors contend that nursing schools tend to marginalize perioperative curricula, which reduces the interest of students in practicing in this area. A survey conducted as part of this study indicated that 77% of the operating rooms in the region had unfilled perioperative-nursing positions. They also reported moderate to severe difficulties with recruitment. A survey conducted of the schools of nursing indicated that 83% did not offer preceptor-ships or clinical internships in perioperative nursing. The authors argue that there is a need for hospitals and nursing schools to form partnerships as a means of providing balanced clinical training for students that can assist in remedying the shortage in this critical specialty. The findings of this study also suggest that the design of the nursing school curriculum has a significant impact in the career choices made by nursing school graduates. 
Trends in Nursing Education
	There is a general trend in the nursing profession to use distance education via the internet as a means of providing graduate instruction to nurses (Huckstadt & Hayes, 2005). A study was conducted to examine the effectiveness of interactive online learning modules for advanced practice nurses. The study also involved the perceptions of the students regarding the strengths and weaknesses of the educational method. The sample consisted of 73 RNs enrolled in either graduate or continuing education programs. The modules contained case studies intended to foster the development of active, apprentice-like learning. Faculty members were also available to interact with the students via email, answering any student questions and fostering electronic discussion of the subject matter with other students in a forum. The study design was quasi-experimental in that it involved the use of pre-and-post tests to determine the change in the understanding of the students of the subject matter. The findings of the study supported the conclusion that the interactive online case-based learning method is successful for advance practice applications. The findings also indicated that the students were particularly enthusiastic about the use of the method, which they perceived as resulting in a significant savings of time. Some of the students, however, reported some degree of difficulty with the tasks associated with the interactive learning process due to insufficient familiarity with computers and the use of the internet to support online learning activities. The study did not discuss the validity or implications of the use of online teaching methods for undergraduate nursing studies.
	The West Virginia University School of Nursing has recently begun offering distance education for its undergraduate nursing students (DiMaria & Ostrow, 2004). The objective for the use of online distance education was to expand the number of students enrolled in the school without expanding the number of faculty positions. Like other schools of nursing, the institution was having difficulty in recruiting qualified nursing educators. The primary criteria for the development of the online learning system was to insure that it did not create any additional work for the faculty, allowing them to leverage the development of a single course curriculum into the ability to provide education to a larger number of students. While the students appear to value the ability to access lecture material on demand, they indicate that the absence of live interaction with peers and instructors is a disadvantage to online learning. The authors suggest that this disadvantage can be remedied through the formation of ad hoc student groups, but this approach presumes that students are located in physical proximity to each other. The University has begun heavily marketing its online nursing degree program, indicating that it will help to alleviate the nursing shortage by training a larger number of nurses with the existing educational resources limited by the availability of faculty.
	Another trend in nursing education is to increase the focus on interdisciplinary learning as a means of fostering a more collaborative approach with other healthcare professionals (Miller, 2004). The majority of the universities in the United States with nursing schools that recognize the need for interdisciplinary learning approach the issue from an academic perspective. In this context, interdisciplinary learning involves orientations and lectures that focus on the role of other professionals in the healthcare delivery system. In most cases, the academic component of this type of learning is provided by faculty members from other healthcare schools such as professors of dentistry or medicine. In some cases, the interdisciplinary curriculum included courses that were open to students from all healthcare disciplines such as healthcare ethics. This type of course was intended to increase the interaction between students in the various disciplines, but retains the academic approach to the issue that is characteristic of nursing and other medical curricula. This approach to interdisciplinary learning in healthcare differs significantly from that used in the United Kingdom, where members of different healthcare disciplines form clinical training teams. As a result, the students receive clinical training as an interdisciplinary group, with each of the students contributing various components of the overall patient care model. 
	Another type of trend in nursing education is to increase the use of role-playing as a substitute for teaching clinical nursing skills (Comer, 2005). This approach involves the use of a patient case simulation in which the students assume the various roles that would normally be encountered in the clinical setting. It is also sometimes used with simulation technology, such as a triage simulation program for computer-enhanced learning. The role play simulation is performed in real time. In this approach, students are presented with a case scenario and are expected to determine the appropriate level of care. The student assigned the role of patient functions from a prepared script that delineates the symptoms and conditions that are involved with the case. The author indicates that the students reported an improvement in their understanding the theoretical academic concepts associated with their coursework as a result of the clinical simulation. In addition, there was a negative correlation between participation in the simulation and the failure rate on examinations. The use of the simulation, however, cannot fully recreate the actual conditions that are experienced in a clinical setting. As a result, the simulation can be considered an extension of academic learning and only tangentially related to the practical knowledge that nursing students obtain from clinical training.
	A major trend in nursing education that has been identified through various surveys is an increased emphasis on technology training (Speziale & Jacobson, 2005). The academic portion of the traditional nursing curriculum has focused heavily on nursing theory and the sciences, with relatively little emphasis on the use of technology in the delivery of nursing care. At the same time, the practice setting where the graduate nurses will be working is increasingly dependent on the use of technologies such as computer systems to support the delivery of healthcare. As a result, many nursing school graduates do not have the range of necessary skills to adequately deal with the technology despite the expectation of the workplace that they will possess the required skills. As a result, the majority of nursing school curricula now contains some level of training in technology. More than 50% of respondents in surveys indicating that technology is receiving greater emphasis in nursing education at the current time than in the past. One of the potential outcomes of this trend is to reduce the amount of time that students spend on other aspects of nursing education, which can have an impact of the quality of nursing education. The nursing schools, however, are responding to the demands of the healthcare system for nursing professionals that have a broad range of technical skills.

Chapter 3 
Methodology
Approach
The research design used in this study involves the use of the descriptive survey method through the development and dissemination of a survey questionnaire as the means of gathering data regarding perceptions of hospital-based nursing education. The research design is based on the premise that this study involves exploratory research to determine the nature of the perceptions in the nursing profession towards hospital-based schools of nursing. The research design is not experimental in nature and uses a post-hoc approach that does not require a control group. The design is intended solely to collect preliminary information to create a greater understanding of the perception of the issues associated with hospital based nursing education. The non-experimental design does not allow the study to exercise as high a degree of control over variables and threats to validity as an experimental design, but nevertheless can produce empirical results in the form of descriptive statistics. The study design is further based on the assumption that attitudes and beliefs regarding a subject such as hospital-based nursing schools are the product of knowledge and experience.
The research design of the study is based on the following four steps:
1.	A review of related literature relevant to the problem under investigation of hospital-based nursing schools
2.	Based on the review of related literature, develop and disseminate a survey questionnaire to the sample population.
3.	Analyze, compare, and develop descriptive statistics based on the recorded data provided by the survey questionnaire.
4.	On the basis of the data analysis, answer the research questions.
The review of related literature provided the foundation for the development of the survey questionnaire by identifying the relevant issues associated with nursing education and hospital-based nursing schools. The survey questionnaire consists of two sections (See Appendix A). The first section is elicits demographic information regarding the position of the respondent in the nursing profession, the length of time the respondent has practiced nursing and the type of nursing degree that the respondent may have. The second section consists of statements regarding nursing education and hospital-based nursing schools. This section of the survey questionnaire uses a five-point Likert-like ordinal scale. The questions require the respondents to rate their agreement with a statement in a range from strongly disagree to strongly disagree. The use of this type of scale establishes greater ease for the coding process of the data produced by the questionnaire, with the coding is based on the ordinal nature of the data that is obtained. The survey questionnaire was designed in a manner that did not require reverse coding of any of the questions.
A statement explaining the purpose of the study accompanies each survey questionnaire. The survey questionnaires are not coded in any manner in order to preserve the anonymity of the respondents. Because of the absence of any type of coding on the survey questionnaires, follow-up for non-respondents was not conducted. As a result, there is an increased risk that the data produced by the survey questionnaire will be influenced by self-selection bias.
Because this study is descriptive and informational in nature, the dependent and independent variables are loosely defined and are not directly related to a hypothesis. The quantitative component of the study is not intended to establish a cause an effect relationship between the variables, although it is likely that such a relationship does exist. It is intended to provide descriptive statistics that can be used to corroborate or refute some of the findings obtained by the qualitative component of the study, which consists of the review of related literature. The purpose of the survey questionnaire is to gather data that can be used to prepare descriptive statistics that identify the perceptions of the study population with respect to hospital-based schools of nursing. 
In the context of the survey questionnaire, the dependent variable is the perception of hospital-based schools of education. This variable is operationalized in the second section of the questionnaire, questions 3 through 10. The independent variables are the demographic variables in the first section of the questionnaire, and questions 1 and 2 in second section of the questionnaire. The design of the survey questionnaire seeks to determine if there are differences in the perceptions of nurses with respect to hospital-based schools based on demographic factors. The three demographic variables are position of the respondent within the nursing profession, educational experience and length of time practicing in the profession. The two independent variables in section two are perception of the importance of clinical training as part of the nursing education curriculum, and perception of the need for nursing students to rapidly complete their education.

Data Gathering Method
	The population for this study consists of all nursing students, practicing nurses, nursing educators and healthcare administrators in a defined geographic area of a single urban center. The sampling technique that was used in the study was systematic random sampling based on the directories of nursing students, practicing nurses, nursing faculty and healthcare administrators. The sampling strategy involved soliciting every tenth individual in the directories for participation in the study via email. The solicitation included an explanation of the purpose of the study and the survey questionnaire. A log was kept of the responses based on email addresses to determine if the individual had responded to the solicitation by completing the survey questionnaire. A follow-up consisting of the original solicitation and survey questionnaire was sent to non-respondents approximately one week after the original solicitation. Although a log was kept of responses bases on email addresses, there was no attempt to correlate completed survey questionnaires with the addresses to preserve the anonymity of the respondents.
	The estimated size of the sample population is 196 respondents, which is based on a confidence level of 95% and a confidence interval of 7. Because the total size of the study population is not known, a larger confidence interval was used to reduce the total number of samples to a manageable number for the purposes of this study. As a result, the findings of the study will be within an interval of 7 in 95% of the results.
	The data gathering strategy called for new solicitations for participation in the study from potential respondents until the minimum number of completed survey questionnaires was received. As a result, new solicitations for participation were distributed by email approximately 2 weeks after the initial solicitation, with the new solicitations following the systematic random sampling protocol. This process produced the 196 samples necessary for the study. The total number of solicitations was 276, which represents a 71% response rate. The response rate is sufficient to reduce concerns regarding self-selection bias in the study, which occurs when the responses are provided only by individuals with a direct interest in the subject material. Self-selection bias can reduce the ability to generalize the findings of a study.
Database of the Study
	The database of the study consists of the primary data obtained through the dissemination of the survey questionnaire and the secondary data obtained from the review of related literature. The data produced by the survey questionnaire is quantitative in nature and supports the development of descriptive statistics in the analysis phase of the study. The data produced from the review of related literature is qualitative in nature and establishes the context for the interpretation of the quantitative data produced from the survey questionnaire. The sources for the data comprising the review of related literature are peer-reviewed academic journals.
Validity of the Data
	To insure the validity of the data obtained by the survey questionnaire, a process of establishing translation and criterion validity was used. The face validity of the constructs used in the survey questionnaire was established by review by nursing professionals to insure that the constructs were understandable to sample population. Content validity was determined through a similar peer review process to insure that the constructs indeed measured the domains that they were intended to measure. Because criterion validity requires that the test instrument be predictive and reliable over time, a pilot test was used that focused on establishing concurrent validity. This pilot test involved the initial dissemination of the survey questionnaire to 20 respondents. Due to the financial and time constraints of the study, the pilot test was relatively small and involved only a limited number of respondents. The data produced by the respondents was used to insure that the survey questionnaire was able to distinguish between the demographic groups and the dependent and independent variables. After criterion validity was established, the survey questionnaires from the respondents in the pilot test were included in the total number of the samples.
Originality and Limitations of the Data
	The originality of the data is due to its close examination of hospital-based nursing education, which is an area of nursing education that had not been widely investigated in past research. The data produced by the survey questionnaire is original in that it is based on primary research through the use of a questionnaire constructed specifically for the purposes of this study. The analysis of the primary and secondary data is also original through the process of synthesizing quantitative and qualitative factors associated with hospital-based nursing education.
	An inherent limitation in the data gathering method that was used in this study is the study population’s access to email and the inclusion of members of the population in directories. Not all members of the population have access to email and many are not listed in directories. The development of methods to remedy this limitation was deemed beyond the scope of this study, which is exploratory in nature. In addition, the data gathering method resulted in the identification of only practicing nurses, with nurses that have left the profession not included in the database produced by the survey questionnaire.
	Another significant limitation of the study is the potential for researcher bias, which is reflected in the overall research process. Researcher bias can be manifested in the process of developing the survey questionnaire and in the selection of materials for the review of related literature that comprises the qualitative database for the study. This type of bias is the result of the pre-existing concepts and opinions of the researcher. In the development of this study, the validity testing of the survey questionnaire reduces the impact of researcher bias. In addition, the selection process for the materials in the review of related literature included data that were both favorable and unfavorable to the concept of hospital-based nursing education. The researcher involved in this study is aware of a pre-existing favorable opinion of the hospital-based nursing school model, and is compensating for the opinion by emphasizing the collection of data that may support an unfavorable view of the model.
	Another limitation of the study is its relatively narrow geographic scope. The data produced by the respondents to the survey questionnaire can potentially reflect local phenomena that are difficult to generalize in a wider context of the nursing profession. As a result, the presence or absence of experience with hospital-based nursing schools and their graduates can significantly influence the perceptions of the respondents. This is an inherent limitation in the design of the study.
Summary of Chapter 3
	The research design for this study used a descriptive survey method that is based on the development and dissemination of a survey questionnaire. The data from the survey questionnaire was synthesized with secondary data obtained from a review of related literature. The population for the study was nursing students, nursing professionals, nursing educators and hospital administrators in a defined geographic area. Systematic random sampling was used to obtain the data. The survey questionnaire was tested for face, construct and criterion validity. The data is original due to the use of a survey questionnaire developed specifically for this study. The study has potential limitations in the data collection method, the possibility of research bias, and its limited geographic scope.
Chapter 4
Data Analysis
Primary Data
	The survey questionnaire produced 196 respondents in accordance with the sampling objective of the study. The first section of the survey questionnaire elicited demographic information to facilitate a comparison between with the data obtained in the second section. Table 1 presents the data obtained from question 1, section 1.
Table 1: Position of Respondents in the Nursing Profession
	Number	Percentage	
Nursing student	67	34.2%	
Practicing nurse	79	40.3%	
Nursing educator	14	7.1%	
Healthcare administrator	36	18.4%	

The percentages of respondents in the various aspects of the nursing profession conform to expectations, with a relatively small percentage expected in nursing education and healthcare administration.
	The second question in section one sought information on the length of time that nurses responding to the survey have been in practice. Because this question excluded nursing students, the total number of respondents was 128. The completed survey questionnaires were carefully examined to insure that students who answered this question were excluded from the responses. Table 2 presents the data obtained from question 2, section 1.
Table 2: Length of Time Respondents Have Practiced Nursing
	Number	Percentage	
Less than 5 years	64	50%	
5-10 years	18	14%	
More than 10 years	46	36%	

	The third question in section one sought information regarding the highest degree level obtained by the respondents, with students asked to indicate the degree that they were pursuing. The data obtained from question 2, section 1 is presented in Table 3. Because the data indicated that only 1 respondent had a doctoral degree and none of the respondents had a diploma in nursing, these categories were omitted from subsequent analysis of the findings.
Table 3: Highest Degree Level Obtained or Pursued by Respondents
	Number	Percentage	
Associates	97	49.5%	
Baccalaureate	51	26.0%	
Master's	47	24.0%	
Doctoral	1	0.5%	
Diploma	0	0.0%	

	Section two of the survey questionnaire elicited information using a Likert-like scale regarding the perceptions of the respondents to a series of statements regarding hospital-based nursing. The raw data obtained from the survey questionnaires provided the basis for the development of descriptive statistics. The analysis of the data involved the development of statistics for the entire sampling and for sub-categories of the sample as defined by the demographic variables in the study.
	Question 1 of section 2 sought information regarding the perceived importance of clinical training in the undergraduate education of the respondents. Table 4 presents the raw data for the respondents.
Table 4: Clinical Training is/was an Important Part of My Undergraduate Training
Strongly
 Disagree			Strongly Agree	
1	2	3	4	5	
12	32	126	18	6	

	When analyzed, the data produced a mean of 2.83, with a mode of 3. This suggests that the respondents slightly disagreed with the statement that clinical training was an important part of their undergraduate education. The standard deviation is relatively small at .78, indicating that the central tendency is towards neutrality, with outliers having a relatively small impact on the data. The data is clustered around the neutral point with the vast majority of respondents neither agreeing nor disagreeing with the statement. When the data from question 1 of section 2 was coded in based on the demographic information obtained in section 1 of the survey questionnaire, it resulted in no significant variation of the findings. In part, this finding was expected because the question was retrospective in nature and was determined by the actual experience of the respondents rather than the perception of the respondents of an ideal experience.
	Question 2 of section 2 sought information regarding the perception of the respondents regarding the importance of nurses completing their education as rapidly as possible, which is indirectly related to the issue of the shortage of nursing. Table 5 presents the raw data provided by the respondents to the survey questionnaire.
Table 5: It Is Important For Nurses to Complete Their Education As Rapidly As Possible
Strongly Disagree			Strongly Agree	
1	2	3	4	5	
0	10	84	75	27	

	This data produced a mean of 3.60 and a mode of 3. The central tendency of the data was towards agreement that nurses should complete their training as rapidly as possible. The standard deviation was .78, suggesting that the mean is reflective of the perception of the group and is not influenced by outliers. As a result, the data was grouped in the neutral to strongly agree range. In addition, none of the respondents strongly disagreed with the statement. When the data was coded based on the demographic information of the respondents, there was a substantial difference in the findings among the nursing educators, which had a mean of 2.6 and among student nurses, which had a mean of 4.1. Because of the relatively small number of respondents to the survey that were involved in nursing education, the findings may not be reliable. In the case of the nursing students, however, the findings suggest that there is a strong desire to complete their education as rapidly as possible. 
	Question 3 of section 2 sought information from the respondents regarding their comparative perceptions of the degree of supervision required for associate degree and diploma nurses after entering the nursing profession as new graduates. Table 6 presents the raw data obtained from the respondents for this question in the survey questionnaire.
Table 6: Compared to associates degree nurses, diploma nurses require less supervision after entering the profession
Strongly 
Disagree			Strongly Agree	
1	2	3	4	5	
6	11	85	63	31	

	The data produced a mean of 3.21 and a mode of 3, suggesting that the study population generally agreed with the statement but had a central tendency towards neutral. The standard deviation, however, was relatively high at .98, indicating that there is a significant divergence of opinion on the issue. As a result, the responses are relatively dispersed with the outliers having a greater impact on the mean. When the data was coded for the demographic variables, a different pattern emerged. Nursing students had a mean score of 2.7, indicating that they disagreed with the statement. In addition, individuals that had an associate degree as the highest level of academic achievement or were currently pursuing the degree had a mean score of 2.5. This group was strongly clustered in the strongly disagree to neutral range, with all of the strongly disagree responses coming from associate degree nurses. In contrast, respondents with degrees at or above the baccalaureate level had a mean score of 3.8. None of the respondents in these demographic groupings indicated that they disagreed or strongly disagreed with the statement. These findings indicate that demographic variables are likely to have a significant influence on the perception of the relative level of supervision necessary for associates degree nurses and diploma nurses.
	Question 4 of section 2 posed a similar question regarding the perception of the level of supervision required for baccalaureate nurses when compared to diploma nurses. Table 7 presents the raw data obtained from the respondents for this question.
Table 7: Compared to Baccalaureate Nurses, Diploma Nurses Require Less Supervision After Entering the Profession
Strongly
Disagree			Strongly Agree	
1	2	3	4	5	
12	51	103	28	2	

	The data produced a mean of 2.78 and a mode of 3, with a standard deviation of .80. This finding indicated that the sample population tended to disagree with the statement suggesting that diploma nurses require less supervision than baccalaureate nurses after entering the profession. The data, however, is relatively tightly dispersed around the mode, although the central tendency is toward disagreement with the statement. The data also suggests that there is a substantial difference in the opinions of the respondent regarding the level of supervision required for associates degree nurses and baccalaureate nurses. This finding is not anomalous due to the fact that diploma nurses have one year more training than associates degree nurses and one year less training than the traditional approach to baccalaureate nurse training. When the data was coded for demographic variables there was a substantial difference in the mean among the healthcare administrators, who had a score of 3.62, and among the nurses with more than 10 years of experience, who had a mean score of 3.25. The hospital administrators were in a relatively narrow cluster between neutral and agree. In contrast, there was a wider degree of dispersion among the nurses with more than 10 years of experience.
	Question 5 of section 2 investigated perceptions regarding whether increasing the number of hospital-based schools of nursing can help reduce the nursing shortage. Table 8 presents the raw data obtained from the respondents for this question.
Table 8: Increasing the Number of Hospital-based Schools of Nursing Can Help Reduce the Nursing Shortage
Strongly 
Disagree			Strongly Agree	
1	2	3	4	5	
6	11	71	87	21	

	The analysis of the data produced a mean of 3.54 and a mode of 4, with a standard deviation of .75. The data suggests that the respondents generally agreed that an increase in the number of hospital-based schools of nursing could help to reduce the nursing shortage. The data is relatively tightly grouped between neutral and strong agreement with the statement, with the relatively high standard deviation suggesting that the outliers have a disproportionate impact on the mean. When the data was coded based on the demographics of the respondents, there was no substantial change in the outcome. As a result, demographic factors did not appear to operate as a modifier for the findings.
	Question 6 of section 2 sought data on the perception of whether it is easier for hospital-based schools of nursing to attract faculty when compared to university-based schools of nursing. Table 9 presents the raw data obtained from the respondents for this question.
Table 9: Compared to University-based Schools of Nursing, it is Easier for Hospital-Based Schools to Attract Faculty
Strongly
Disagree			Strongly Agree	
1	2	3	4	5	
2	54	127	12	1	

	The data for this question had a mean of 2.77 and a mode of 3, indicating that the sample population disagreed with the statement. In addition, the standard deviation was very low at .59. The data is narrowly grouped between disagree and neutral, with the outliers having a relatively small impact on the mean. As a result, the findings suggest that the respondents did not perceive any significant differences between university-based schools of nursing and hospital-based schools of nursing in their ability to attract faculty. There was no substantial difference for the data when it was coded for the demographic variables.
	Question 7 of section 2 sought data regarding the perception of whether hospital-based schools of nursing reduce costs for the profession by providing extensive clinical training. Table 10 presents the raw data from the survey for this question.
Table 10: Hospital-based Schools of Nursing Reduce Costs for the Profession by Providing Extensive Clinical Training
Strongly Disagree			Strongly Agree	
1	2	3	4	5	
2	14	71	86	23	

	 The analysis of the data resulted in a mean of 3.58 and a mode of 4. This suggests that the respondents perceived hospital-based nursing schools that provide clinical training as capable of reducing costs for the profession. The standard deviation was .84, which is relatively high compared to the other responses on the survey questionnaire. While the data indicates that there is relatively high agreement with the statement, the outliers on the disagreement side tend to reduce the value of the mean. When the data was coded by demographic variables, there were some substantial variations. Among the respondents who were students, the mean score was 2.95, suggesting that students perceived hospital-based nursing schools as increasing rather than decreasing expenses for the nursing profession. The findings for this group were clustered between the range of disagree and neutral, with the outliers having only a minimal influence on the mean. In addition, the respondents who had less than 5 years of practice experience had a mean score of 3.05 with the responses clustered close to the neutral point. Although these scores indicated some degree of neutrality towards the issue, they nonetheless were a downward divergence from the mean of the full group of respondents.
	Question 8 of section 2 sought information regarding the perception of whether hospital-based schools	provide effective clinical training. Table 11 presents the raw data from the survey for this question.
Table 11: Hospital-based Schools Provide Effective Clinical Training
Strongly Disagree			Strongly Agree	
1	2	3	4	5	
0	8	85	77	26	

	When analyzed, the data produced a mean of 3.61 and a mode of 3. This indicates that there was general agreement among the respondents that hospital-based schools of nursing provide effective clinical training. The standard deviation was .76, with the data relatively tightly grouped in the neutral to strongly agree range. There were no substantial variations in the findings based on the demographic variables.
	Question 9 of section 2 sought data regarding the perceptions of the respondents regarding whether hospital-based schools adequately prepare candidates for the NCLEX-RN examinations. Table 12 presents the raw data produced by the survey questionnaire.
Table 12: Hospital-based Schools Adequately Prepare Candidates for the NCLES-RN Examination
Strongly
Disagree			Strongly Agree	
1	2	3	4	5	
0	2	67	85	42	

	The analysis of the data resulted in a mean of 3.85 and a mode of 4, indicating relatively strong agreement among the respondents that hospital-based nursing schools adequately prepare candidates for the NCLEX-RN examination. The standard deviation was .76, which suggests that the findings are narrowly grouped in the neutral to strongly agree range. The outliers in the range of disagree and strongly disagree are negligible. There were no significant differences in the findings when the data was coded in accordance with the demographic variables.
	Question 10 of section 2 sought information regarding the perception of the balance between academic and clinical training during undergraduate education. Table 13 presents the raw data obtained from the survey questionnaire.
Table 13: Nursing Education at the Undergraduate Level Requires a Balance Between Academic and Clinical Training
Strongly
Disagree			Strongly Agree	
1	2	3	4	5	
0	6	118	56	16	

	The analysis of the data resulted in a mean of 3.41 and a mode of 3, indicating that the respondents perceived that there should be a balance between academic and clinical training in undergraduate nursing schools. The standard deviation was .68, with the data relatively tightly grouped around the neutral to agree range. The data dispersion suggests that despite the agreement to the proposition, there is some ambivalence on the issue, with the majority of respondents neutral. When the data was coded by demographic factors, a different pattern emerged. Associates degree nurses were strongly clustered around a score of 3.0, suggesting that they neither agreed nor disagreed with the proposition. The nurses with more advanced degrees, however, were more heavily clustered around the score of 3.85, suggesting that the level of education of the respondent influences the perception of the issue. In addition, the highest scoring demographic group was among the nursing educators, which had a mean score of 4.3.
Secondary Data
	The secondary data consists of the information obtained from the review of relevant literature. The analysis of the data from these sources is qualitative in nature and involves the identification of the general themes that are found in the various discussions of hospital-based nursing schools and the factors that influence educational paradigms in nursing. This type of approach is necessary because of the absence of empirical investigations regarding nursing education models.
	The original model for nursing education in the United States involved the use of training schools for nurses associated with hospitals. This model was largely based on the British training schools for nurses established by Nightingale. In part, this movement was prompted by the shortage of nurses during and after the Civil War, and was intended to ensure that nurses had a minimum level of training (Donahue, 1996). In practice, the absence of a national standard for nursing schools resulted in a high degree of variability in the quality of nurse training in these hospital-based schools. This led to the development of the university-based model for nurse education in the beginning of the twentieth century.
	A number of factors appear to have been involved with the desire to develop nursing schools independent of hospitals. The role of nursing gradually evolved to include the need for scientific knowledge as well as clinical decision-making for nurses working independently from hospitals. The hospital-based schools as they existed at the time had an exclusive clinical focus and assumed that nurses would be constantly under the supervision of physicians. As a result, there were little more than training schools with nursing viewed as a trade rather than as a profession (Asubonteng, McCleary & Munchs, 1995) Developing a separate type of nursing school connected with a university would achieve the objectives of improving the quality of the scientific education for nurses. Another factor involved with the development of university-based nursing schools was the desire of the nursing profession to enhance its status in the healthcare community. The baccalaureate degree offered by these institutions conferred a higher degree of credibility on its graduates compared to the diploma issues by the hospital-based training schools (Lusk & Robertson, 2004). In addition, developing a separate system of university-based nursing schools was a more efficient educational model for nursing education to pursue compared to attempting to reform the curricula in a diverse and poorly regulated body of hospital-based training schools. 
During the period when university-based nursing schools were developing, there was some degree of competition with training schools for nursing students. University-based nursing schools were able to obtain endowments through their affiliations with universities, which provided the means for these schools to become the dominant paradigm in nursing education (Donahue, 1006). At the same time, the competition for students with university-based nursing schools forced the hospital-based schools to reform their curricula to include a greater degree of instruction in the sciences and nursing theory. The hospital-based schools, however, retained their strong clinical focus as a result of their affiliations with hospitals.
The system of nursing education again underwent change following World War II, with the shortage of nurses prompting the development of the associate degree method of entering the nursing profession (Haase, 1990). This change in the structure of the professional education was intended primarily to rapidly increase the number of nurses. The associate degree enabled individuals to qualify for the RN examination with only two years of formal education that primarily stressed nursing theory and the sciences. The development of the two-year nursing school associated with universities and colleges further intensified the competition with the hospital-based nursing schools. Students could enter the profession with a reduced financial and time commitment. The profession justified the development of this shortened program by contending that the nurses receiving an associate’s degree would eventually continue their education to obtain a baccalaureate degree.
While the university-based educational model for nursing retained some aspects of clinical training, it did not provide the extensive amount of clinical training as occurred in the hospital-based nursing schools. The degree programs at the associates and baccalaureate levels are primarily aimed at teaching theoretical and academic skills. In the case of the associates program, the time period for acquiring sufficient skills to perform adequately on the NCLEX-RN examination is extremely compressed. As a result, there is very little time available for students to have an extensive amount of clinical training. At the baccalaureate level, there are a number of educational requirements imposed by the university, which also reduces the amount of available time for clinical training (Haase, 1990). 
The data regarding the historical development of the hospital-based and university-based nursing schools is generally impartial and does not attempt to make a value judgment regarding the effectiveness of the different educational models. The data generally suggests that changes in the structure of the nursing educational system were a response to changes in the social, scientific, and healthcare environment. The implication of the historical trends is that nursing education is likely to continue evolving in response to the environment.
Some evidence of the current type of evolution in nursing education is the increased use of distance education methods to increase the enrollment in university-based nursing schools (Huckstadt & Hayes, 2005; DiMaria & Ostrow, 2004). While this type of program can address issues such as the overall nursing shortage, it further reduces the clinical training component of nursing education and increases the emphasis on didactic education. Another type of ongoing change in nursing education involves the use of computer assisted programs and role-play simulations to assist in developing clinical judgment (Comer, 2005). This type of educational method is a response to the demand among nursing students for programs that can be completed in a minimal amount of time. The academic content of nursing programs is also changing through the inclusion of interdisciplinary and technology related material (Miller, 2004; Speziale & Jacobson, 2005).
	The data also indicates that the issue of the shortage of nurses is related to the way in which nursing education occurs. In certain critical specialties such as perioperative nursing, the absence of sufficient exposure to the specialty during the educational period through clinical rotations contributes to the shortage of nursing (Ward & Saylor, 2002). In addition, there is evidence that an increase in clinical experience of nurses during their education improves the quality of their education, and can reduce the amount of time involved with clinical training and supervision after they enter the profession (Lindeman, 2000; Daelmans et al, 2004). 
	Despite the benefits of including an extended period of clinical training in the nursing curriculum through institutions such as hospital-based schools of nursing, there remains strong resistance to the concept. Three-year hospital-based schools must compete with two-year associates degree schools and four-year baccalaureate schools for enrollment. Because the three-year school creates a delay for students in entering the workforce, they are unlikely to draw enrollment away from associates degree programs (McNamara, 2000). Similarly, the hospital-based schools of nursing are unlikely to draw enrollment from the four-year schools of nursing because they grant a diploma rather than a baccalaureate degree.
	The findings from the examination of the qualitative data indicate that nursing education is attempting to balance conflicting demands of improving quality and increasing the number of graduates to meet the demands of the healthcare system. While some of the evidence suggests that increased emphasis on clinical training would be welcome for the nursing profession, the dominant priority of nursing education appears to focus on rapidly increasing the number of graduates. In this context of competing priorities, the possibility that hospital-based schools of nursing could provide the means to balance the conflicting demands of nursing education is not directly evaluated.

Chapter 5
Summary, Conclusion and Recommendations
Summary
	This study examined hospital-based nursing schools in the general structure of nursing education programs to determine if the hospital-based educational model is advantageous for modern nursing practice. Hospital-based nursing schools are three-year educational institutions that are associated with a hospital, offer a diploma in nursing, and qualify graduates to take the NCLEX-RN examination. There are very few diploma in nursing programs remaining in the United States, with the university-based two-year associate degree and four-year baccalaureate degree programs producing the vast majority of nursing graduates. The problem with the university-based model in nursing education is that it provides insufficient clinical training for nurses as undergraduates. As a result, nurses must obtain the majority of clinical training after their entry into the workforce, with the employer bearing the cost of training and lower productivity during the training period.
	This study investigated the perceptions of nursing professionals towards hospital-based nursing schools by means of a survey questionnaire and an examination of the existing literature regarding the issues associated with hospital-based nursing schools. The survey questionnaire provided the means to develop descriptive statistics while a review of related literature provided the means to identify the perceived needs and trends of the profession with respect to nurse education. The quantitative aspects of the study involved the use of systematic random sampling among nursing students, practicing nurses, nurse educators and healthcare administrators. The qualitative aspects of the study involved an examination of secondary source data to determine whether hospital-based nursing schools are a viable educational model for the nursing profession.
	The data produced by the dissemination of the survey questionnaire indicated that there was generally a favorable opinion of hospital-based nursing schools with respect to the quality of the nursing graduates. At the same time, the data indicated that the highest priority for the profession was to insure that nurses graduated as rapidly as possible in order to enter the workforce and alleviate the nursing shortage. The data also suggested that there was a positive perception towards increasing the number of hospital-based nursing schools as a means of reducing the nursing shortage.
	The data produced from the review of related literature indicates that the current model for nursing education evolved in response to various historical situations and continues to evolve in response to the perceived needs of the profession. These secondary sources do not generally evaluate the viability of the hospital-based school of nursing in the context of the current nursing education system. They do function to identify a number of issues that are given a high priority by the profession such as the shortage of nurses and the need for increased amounts of clinical training for undergraduate nurses. The secondary data further indicates that clinical training has a high degree of importance for nursing practice. 
Conclusions
	The findings of the study generally support the general alternative hypothesis, which contends that hospital-based nursing schools provide a significant advantage for the nursing profession when compared to university-based nursing schools. The primary data obtained by the survey questionnaire indicated that there was a perception among the respondents in the nursing profession that hospital-based schools could reduce costs for the profession, provide effective clinical training and adequately prepare candidates for the NCLEX-RN examination. In addition, there was general agreement that nursing education requires a balance between academic and clinical training. The areas in which the data did not support the hypothesis was in the perceived need for nurses to complete their training as rapidly as possible. Because the hospital-based programs are three years in duration, they are lengthier programs than the two-year associates degree programs.
	The first research question investigated the advantages for nursing students at hospital-based nursing schools. The primary data from the survey questionnaire indicated that graduates of hospital-based nursing schools require less supervision after entering the profession when compared to nurses graduating form associates degree programs. In addition, hospital-based nursing schools provide the advantage to the student of more extensive and effective clinical training. As a result, the primary advantage to the student is the balance between academic and clinical training that takes place in the hospital-based nursing schools. The student receives the same level of academic education as in the two-year associates degree program, which prepares them for the NCLEX-RN examination. At the same time, they receive a clinical education that is superior to that of the university based schools. 
	The second research question investigated the advantages for the nursing profession of hospital-based nursing schools. The primary data obtained from the survey questionnaire indicates that the perceived advantage of hospital-based nursing schools for the profession is a reduction in costs and an improvement in the professional quality of newly graduated nurses. The reduction in costs comes from a lower level of supervision that is necessary for graduates from hospital-based nursing schools. In addition, there are cost savings for the profession in terms of reduced risk due to the higher level of clinical expertise among newly graduated nurses from these types of schools. Another potential advantage for the profession can come from increasing the number of hospital-based nursing schools, which can produce a larger number of nursing graduates. The larger number of graduates can help to reduce the nursing shortage.
The secondary data suggests that hospital-based nursing schools would not be successful in attracting enrollment because of the shorter training period available with the associates degree option for nursing education (McNamara, 2000). The secondary data, however, also indicates that there are significantly more applicants for nursing school than can be accommodated by existing positions in institutions (Brunnel, 2005). The development of additional hospital-based nursing schools are less likely to face significant competition issues in a market that is characterized by supply of nursing school seats insufficient to meet the high demand. 
The third research questions examined the disadvantages of hospital-based nursing schools for students and for the profession. From the perspective of the student, the hospital-based nursing school involves a higher personal cost than the associates degree program due to the need to attend nursing school for an additional year. The costs are direct in the form of tuition and indirect in the form of the foregone opportunity to enter the nursing workforce and earn wages during the third year of hospital-based nursing school education. The salary structure of the nursing profession also creates a disadvantage for students who attend hospital-based nursing schools. In general, the starting salaries of two-year associates degree nurses and three-year diploma nurses are on a par, resulting in a disincentive for students to attend three-year schools. Another type of disadvantage comes from the status of the diploma awarded by the hospital-based nursing school in the context of the professional development of nurses. There remains an expectation in the profession that diploma nurses will eventually complete the baccalaureate degree as prerequisite for advancement within the profession (D’Antonio, 2004).
The primary disadvantage to the profession of hospital-based nursing schools is the additional year of training for students in these schools when compared to associates degree programs. Because of the current shortage of nurses, the profession needs as many nursing graduates as possible in the shortest period of time. While the additional year of clinical training in hospital-based nursing schools can benefit the profession in the long run, it does not provide for more rapid training of nurse graduates in the short run. Another perceived disadvantage of hospital-based nursing schools involves the historical development of nursing education, with lower status accorded to nursing schools associated with hospitals. These schools have been traditionally viewed as providing insufficient academic education in a standardized manner. While hospital-based schools may have been merely training centers during the nineteenth century, they are capable of providing both academic and clinical education in the modern environment.
The fourth research question investigated the barriers inhibiting the expanded use of hospital-based nursing schools. The secondary data from the study indicates that the barriers are attitudinal, financial, and faculty related. The attitudinal barriers are a legacy from the historical period when the nursing profession was emphasizing university-based education as the preferred alternative to hospital-based education. As a result, there is a bias in the profession towards educational institutions that are independent from a university or college. The bias against hospital-based nursing schools influences the way in which the profession approaches developing solutions to problems such as the shortage of nurses (McNamara, 2000).
There are significant financial barriers to the expanded use of hospital-based nursing schools. The costs of operating a nursing school are relatively high, with the tuition paid by students generally insufficient to meet the full range of costs. Hospital-based nursing schools have not traditionally attracted the same level of endowments as university-based nursing schools to assist in defraying the cost of operations (Donahue, 1996). At the same time, hospitals are faced with significant financial difficulties and do not generally have the resources to operate a nursing school that may not provide direct revenue enhancement. Some of the costs involved with providing clinical training are borne by the hospitals in the form of decreased productivity for student supervisors and increased costs for risk management. Although some of the costs for clinical training of nurses prior to graduation from nursing schools are borne by Medicare reimbursements to hospitals, this funding represents only a small percentage of the total costs involved with clinical training of nurses.  
The faculty related barriers inhibiting the expanded use of hospital-based nursing schools are related to the general shortage of nursing faculty in the profession. At the current time, there is competition between private industry, hospitals and educational institutions to attract nurses with advanced academic degrees (Evans, 2005). In addition, there is competition among educational institutions for faculty, with factors such as salary range, status of the institution and geographic location influencing the decision to accept a faculty position. The ability to attract faculty is an inherent constraint in the development of new schools of nursing.
The fifth research questioned examined whether there are any current efforts to promote hospital-based schools of nursing. The data indicates that there are no significant efforts to promote hospital-based schools of nursing in the United States neither as a means to improve the quality of nursing education nor as a means of alleviating the nursing shortage. In part, the absence of interest in the use of the hospital-based model is due to the high priority placed by the profession on increasing the number of practicing nurses as rapidly as possible. The efforts to promote hospital-based schools of nursing largely consist of assessments of the value of additional clinical training for nurses prior to their entry into the profession. This type of approach is based on the assumption that hospital-based schools of nursing provide a greater degree of clinical training for undergraduate nurses. Hospital-based schools of nursing, however, are being actively promoted in many other nations such as Canada and the United Kingdom that face difficulties with nursing shortages that are similar to those in the United States. It is possible that the successful use of the model in other nations may result in greater awareness of the benefits that hospital-based schools can provide to the process of educating nurses and to the profession in general.
The sixth research question investigated the position of proponents of degree-based programs regarding hospital-based nursing schools. The general position of advocates of university-based nursing schools is that the academic and didactic approach to nursing education is the model that is best suited to meet the needs of the profession and of the students. Mastery of the academic component is necessary for graduates to pass the standardized NCLEX-RN test that allows entry into the professional workforce. Proponents argue that this is best accomplished with a curriculum that emphasizes the theoretical and scientific aspects of nursing. Although hospital-based nursing schools provide the same type of academic training as two-year university-based programs, there is only limited recognition of the academic viability of these programs. The primary argument used by proponents of university-based programs to support the superiority of the current educational model is the need to rapidly educate nurses to remedy the nursing shortage. This perspective views the additional year of clinical training, that occurs in the hospital-based nursing schools, as unnecessary.   Graduate nurses are left to remedy any deficiencies in their clinical training after they enter the professional workforce.
The general conclusion of the study based on the investigation of the research question is that the hospital-based nursing school model can provide significant benefits for the profession of nursing, although there are barriers to the use of the model. The primary data collected for the study indicates that members of the profession believe that increasing the number of hospital-based nursing schools can help to reduce the nursing shortage. In addition the primary data shows that there is a perception among practicing professionals that hospital-based nursing schools provide effective clinical education that is superior to the clinical education received at least by two-year associates degree nurses. The profession also believes that hospital-based nursing schools are at an academic par with university-based schools as determined by their ability to prepare graduates for the NCLEX-RN examination.
The barriers to fostering the growth of hospital-based nursing schools are largely the result of the way in which nursing education has evolved over the past century. The profession initially created the university-based educational model to remedy shortcomings in the quality of the nursing educational process. An educational model that was separate from the early hospital-based system was necessary to insure that nurses received sufficient education in the sciences and the theoretical aspects of nursing. The university-based system responded to the increasing shortage of nurses by developing a two-year educational program that allowed nursing candidates to enter the profession more rapidly, focusing on fundamental training in the sciences and nursing theory. This approach that involved shortening the educational period, however, has resulted in the development of quality issues with respect to clinical education that are analogous to the quality issues that initially prompted the development of the university-based nursing schools. 
The general conclusion of the study also supports the argument that hospital-based nursing schools represent a viable means to address the issues of the quality of nursing school graduates and the shortage of nurses. The additional year of clinical training that graduates from hospital-based nursing schools receive can improve the level of clinical knowledge and reduce the need for clinical training after the graduate has entered the workforce. An increase in the number of hospital-based nursing schools could also reduce the nursing shortage by increasing the aggregate number of nursing school seats that were available to candidates. The expansion of hospital-based nursing schools, however, requires some degree of restructuring in the funding mechanisms for nursing education to allow these types of schools to operate.
The findings of this study have implications for the way in which nursing education is conducted in the United States. The study has determined that there is a perception among nursing professionals that additional clinical training is necessary for undergraduate nurses. In addition, it has determined that hospital-based schools of nursing represent a viable method to provide the necessary training. The findings of this study should not be considered conclusive, however, due to the exploratory nature of the research and the limitations of the research design.
Recommendations
	This study found that the issues associated with hospital-based schools of nursing have not been extensively researched. Further research should be conducted on the issue of hospital-based nursing schools with an empirical focus to develop quantitative evidence of the viability of the educational model in the context of the profession. This type of research should examine the costs associated with providing nursing education in the hospital-based environment and a comparison with the costs in the university-based environment. In addition, it should investigate quality outcome in both types of programs based on the development of measures for clinical quality that are not associated with the NCLEX-RN passage rates. Research should also investigate the actual attractiveness of the hospital-based nursing school option to prospective candidates in the nursing profession as a means of assessing demand for this type of education. Additional research should also be conducted regarding the specific nature of the barriers to the development of hospital-based nursing schools in quantitative terms in order to develop clearly defined strategies for overcoming the barriers.

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Appendix A
Survey Questionnaire
This survey is intended to gather information about your perceptions of hospital-based nursing schools and their role in nursing education. 
Section 1: Please indicate your answer to the following questions.
1. I am a 
Nursing Student_____		Practicing Nurse_____
Nursing Educator_____		Healthcare Administrator_____
2. If you are not a student, how long have you been practicing nursing?
Less than 5 years ______		5-10 years _____
More than 10 years______
3. Please indicate your highest degree level. (Students, please indicate the degree that you are pursuing).
Associates Degree ______		Baccalaureate Degree _____
Master’s Degree   ______		Ph.D. _____
Diploma in Nursing _____
Section 2.
The following section consists of statements regarding nursing education and hospital-based nursing schools. A graduate from a hospital-based nursing school is referred to in the questions as a diploma nurse. Please indicate your agreement or disagreement with the statements by circling your response. A rating of 5 means that you strongly agree with the statement while a rating of 1 means that you strongly disagree with the statement.
						Strongly                         Strongly
                            		Disagree				   Agree
					
1. Clinical training is/was
an important part of my 
undergraduate education  	   1      2      3     4     5
2. It is important for nurses
to complete their education
as rapidly as possible.          1      2      3     4     5
3. Compared to associates degree 
Nurses, diploma nurses require
less supervision after entering
the profession.                   1      2      3     4     5
4. Compared to baccalaureate 
Nurses, diploma nurses require
less supervision after entering 
the profession                     1      2      3     4     5
5. Increasing the number of 
hospital-based schools of nursing 
can help reduce the nursing
shortage                           1      2      3     4     5 
6. Compared to university-based
schools of nursing, it is easier
for hospital-based schools 
to attract faculty                 1      2      3     4     5
7. Hospital-based schools of 
nursing reduce costs for the
profession by providing extensive
clinical training                   1      2      3     4     5
8. Hospital-based schools provide 
effective clinical training         1      2      3     4     5
9. Hospital-based schools
adequately prepare candidates
for the NCLEX-RN examination        1      2      3     4     5

10. Nursing education at the 
undergraduate level requires 
a balance between academic and 
clinical training                    1      2      3     4     5