Making The Grade
Students pursuing a Bachelor of Science in Nursing (BSN) degree at the University of Kansas closed out the 1959 calendar year with the knowledge that the academic quality of their education was now confirmed and acknowledged across the nation.
On December 16, 1959, the Department of Nursing Education at the KU School of Medicine received formal word that the National League for Nursing had voted to grant full accreditation to KU’s baccalaureate in nursing program. The announcement marked the final step in a lengthy process to achieve accreditation for a degree that had been established 30 years earlier. This outcome meant that students who had earned a BSN from KU could do graduate work at other institutions with instant acceptability. It also meant that the KU nursing education program had completed a long series of curricular self-assessment efforts, and had made improvements and enhancements when necessary.
In many ways, the route toward achieving academic accreditation began as early as 1929 when the University formally enrolled its first handful of BSN students. In the years that followed, the curriculum and teaching style gradually changed from the original Florence Nightingale plan of apprenticeship training in the “arts of nursing” to an academically rigorous set of courses and clinical training resulting in greater knowledge of the “science of nursing.” Along the way, the vocation of nursing became the profession of nursing.
When the University of Kansas Nurse Training School began on October 1, 1906, it was modeled in part after the Nightingale system practiced in Great Britain, Canada and much of the United States. Nurses learned by doing, observing and, for about five or six hours a week, hearing lectures by Medical School doctors describing their area of specialty. Most of the nursing instruction came as the students worked their 12-hour shifts six days a week, 49 weeks a year at KU’s Eleanor Taylor Bell Memorial Hospital in Rosedale. (One significant difference between the Nightingale methodology and the KU approach was the latter’s development as a university-based educational program.)
Most of the responsibility for instruction of KU nursing students in these early years fell on the women who, despite their various titles, were essentially the head nurse at this hospital. The double-duty regimen wasn’t always optimal. For example, there were some weeks when Pearl Laptad, KU’s first nursing instructor and supervisor, was so absorbed by her hospital administrative duties that “pupil” nurses were often “on their own” to provide necessary bedside care for hospital patients.
From its inception, Bell Memorial Hospital operated as a part of the Medical School primarily as a learning laboratory for student doctors and nurses. The difference was that professional attending physicians bore medical responsibility for the patients while the student nurses performed most of the actual duties in the wards. The student nurses always maintained greater contact with the patients throughout their hospital stay.
When the medical students completed their four years of study – initially two years of scientific courses in Lawrence at KU’s main campus and two years of clinical work at the hospital in Rosedale (later a part of Kansas City, Kansas) – they received the degree of Medical Doctor. The nursing students, on the other hand, after three years of work and study received a non-academic diploma that simply certified their completion of the program.
In the early years doctors and nursing education advocates tended to agree that the apprenticeship system of instruction and the resulting non-academic certification was enough. With the arrival of Henrietta Froehlke as director of nursing education in 1927, the transition from apprenticeship to academic training began in earnest.
Froehlke was the first person to hold the position who had herself gained a graduate degree in nursing education. She knew that if the nursing education program were to thrive within the University, it had to have an academic degree as its culmination. After a great deal of effort within the College of Arts and Sciences on the Lawrence campus which would provide the first three years of instruction, she obtained approval of the BSN program to go into effect on September 17, 1929.
Such a move did not end the apprenticeship approach all at once. According to Hester Thurston, who prepared a paper about the history of the KU School of Nursing in the early 1980s, Froehlke “did not discontinue the diploma program” when the degree was instituted. For the next 22 years students were accepted into either track of nursing education. The diploma or certificate program required only that entrants had completed high school. The new BSN degree curriculum required that accepted candidates had finished 94 credit hours in liberal arts and sciences. The BSN students then worked and studied at Bell Memorial Hospital for two calendar years rather than the three full years required for diploma qualification.
In 1932, Froehlke negotiated faculty rank for herself as Associate Professor of Nursing. She also achieved faculty status for several of her assistants and nursing instructors. These advances marked additional essential steps along the road toward achieving accreditation. Initially, the nursing education program attracted few applicants for the BSN degree option. It meant six semesters of normal liberal arts coursework at the main Lawrence campus of the University followed by two full years, including summers, at the medical school hospital in Kansas City. Through the 1930s more applicants chose the three-year diploma path over the five-year degree option.
Also during the 1930s, monthly student nurse stipends ended and tuition began to be charged which further enhanced the understanding of those in nursing as “students” rather than “employees” of the hospital. As Shirley Veith has noted in her 1988 doctoral dissertation on the development of the nursing profession at KU, Froehlke’s hope was that money obtained by these changes could be used to hire more graduate nurses for the hospital, but the funds went elsewhere. According to Veith, Froehlke observed that it took time “…to educate men to the needs of student nurses and patients.”
A boost of sorts came to the academic degree program in 1936 when the Division of Home Economics at Kansas State College (an early predecessor to the present-day College of Human Ecology at Kansas State University) in Manhattan obtained approval for a five-year program in Home Economics and Nursing with candidates completing the final two years in clinical work at Bell Memorial Hospital in Kansas City. For many years, roughly a fourth of the BSN students came through this K-State home economics track.
In part because of pressures for more education for women during the Great Depression, and in part because of the influx from Kansas State, by 1940 the degree program attracted forty-eight students while fifty-two followed the three-year diploma option.
Accreditation definitely came to the forefront of the nursing effort in 1938. When the National League for Nursing Education (later shortened to the National League for Nursing) promulgated plans to establish itself as the collegiate accrediting agency, the organization included Bell Memorial Hospital and the KU’s nursing education program in its survey. After a two-day onsite inspection, however, the League visitors identified so many problems and challenges for the program that Froehlke did not believe that formal application for accreditation should be made at that time.
The problems identified included the low number of actual hours of instruction, the quite high requirement of 60 clinical work hours per week and the subservient position of the nursing education program as simply a department of the School of Medicine. Additionally, the visitors’ report criticized the low number of graduate nurses working in the hospital that, in turn, placed even more responsibility for daily bedside work on the student nurses. One student nurse was quoted in the Veith dissertation as saying, “It was something to put an eighteen-year-old in charge of thirty patients.” Quite often this appears to have happened, especially on night shifts.
Because of the interruptions of World War II and its aftermath, the Nursing Education Department did not again attempt to gain National League for Nursing accreditation until the early 1950s after the arrival of E. Jean Hill as director of nursing and department chair. Medical School Dean Franklin Murphy appears to have hired Hill precisely because he thought she could secure accreditation for the nursing education department.
When interviewed late in life, Hill was asked what she remembered about the process of gaining accreditation. Since it took 10 years after her arrival to achieve full NLN accredited status, her interviewer must have expected a lengthy answer. Instead Hill responded that she did not remember any specifics: “I think I took it for granted that we would get accredited.”
That sort of confidence on the part of Hill was probably helpful in the process, but in fact there was much that had to be refined. A complete curriculum overhaul was accomplished between Hill’s arrival in 1949 and the granting of full accreditation in 1959. In 1950, the three-year diploma program still existed alongside the more academic BSN curriculum. In reality, they were much the same program except that diploma candidates did not have to complete the college coursework required of degree-seeking student nurses.
The final course catalog to list both programs stated that the degree program included 84 credit hours of instruction in addition to two hours per week of clinical instruction in the wards. In contrast, the diploma students had instructional time listed in clock hours, not credit hours. The primary difference between the two programs lay in the amount of work performed in addition to academic coursework by the diploma students. They averaged over 25 hours per week in regular patient care while the degree students had clinical patient responsibilities of closer to half that amount.
The dropping of the diploma program that became effective in 1951 meant that future students would have more academic class time and less patient care time in the wards. The end of the diploma program was likely the result of preparations for the evaluation visit by National League for Nursing accreditation visitors in 1952 that gave the department temporary accredited status.
Interestingly, in part to compensate for the discontinuance of the diploma option, the Florence Cook Department of Practical Nursing in the Department of Nursing Education at KU first accepted students in that same year. This was a 12-month training program that included four months of classroom instruction and eight months of clinical work in Bell Memorial Hospital with the regular nursing staff and faculty providing instruction throughout. At the completion of the 12 months, the practical nurses received certificates of completion that entitled them to take the State Board examination to become Licensed Practical Nurses (LPNs). This program was especially designed for young women who planned to serve in the less populated sections of Kansas as a part of the Rural Health Plan for Kansas developed by Franklin Murphy when he was dean of the Medical School
It is possible that the move toward a strictly baccalaureate degree for nurses resulted in a more assertive group of graduates in their field. Researcher Shirley Veith found that diploma program students often spoke of “their care-taker role as secondary to obeying and respecting doctors.” They were convinced of their inferiority and the need for their subordination to the medical profession.
However, baccalaureate nurses more frequently found “the physician-nurse relationship…demeaning to nurses and harmful to the development of the occupation.” A nurse who had earned a BSN in 1941 observed, “I think the doctors were trying to usurp the field of nursing, and took the authority from nurses. But, because of the status of women in society, students were oriented to take whatever physicians dished out.” If such views were accurate, the elimination of the diploma program initiated by Department Chair Hill and approved by the Medical School governing members augured much change for doctor-nurse relations in the future.
As a result of the curriculum changes initiated by Hill and the efforts of the Department of Nursing Education staff, the program received temporary accreditation approval from the National League for Nursing late in 1952. All students entering the department after the beginning of spring semester on February 5, 1953, did so with the knowledge that they were participating in at least a provisionally accredited program of instruction.
Over the next seven years the department was involved in a series of curriculum revisions and efforts to upgrade departmental offerings. As part of this advance, Hill was promoted to full professor of nursing with an annual salary of $6,500 for a 12-month contract. Both the title and the salary level were the highest awarded to a KU Department of Nursing Education faculty member up to that time. The fact that the department chair also held her appointment as a full professor gave Hill added clout with other administrators in the School of Medicine.
In August 1954, the Department of Nursing Education announced a curricular revision that made it a 48-month program, covering four and one-half calendar years. Students at KU or at other colleges or junior colleges across the state with approved curricula would now take four semesters and one summer at their original institution followed by nine quarters in clinical areas of instruction at the KU Medical Center in KCK (normally covering 27 calendar months including some vacation time). This was a reduction of six months in the overall length of completion and brought the KU program more in line with national trends.
In an extremely important change in 1956, a director of nursing service, Harriet Arnold, was appointed for the first time, allowing the chair of the Department of Nursing Education to devote full time to academic administration. This was not the first time such a division of labor had been attempted, but from this date forward, the separation of supervision of nursing in the hospital from the academic leadership of the department was complete. The educational program could grow under its own impetus from this year forward. Also, by this time, students were required to work “service time” as part of their training, but the educational component always came first.
In a further demonstration of the robust nature of the academic program, on June 3, 1956, 32 young women completed the BSN degree requirements. Twenty-four received the Bachelor of Science in Nursing degree from the University of Kansas. Eight, or one-fourth of the total, were awarded the Bachelor of Science in Home Economics and Nursing from Kansas State University.
The next step toward full accreditation by the National League for Nursing Education came in 1957 when the department’s “temporary” accreditation advanced to “provisional” status. This improvement came about after the administration and faculty had conducted additional self-study efforts and filed volumes of reports and evaluations.
The final level of full accreditation came in 1959. By this time, the academic program at the Medical Center had been reorganized into quarters with the coursework adjusted to permit completion within twenty-four calendar months. Students admitted to the program began in the first summer with nine hours of biology classes and lab study at the Lawrence campus.
From September of their first year through May of their second in Kansas City, the students completed 59 credit hours in specific coursework such as Foundations of Nursing, Methods of Teaching, Introduction to Ward Administration and various specialty nursing areas. The 45 calendar months spent at the Medical Center also included 1,120 clinical practice hours and fulfillment of one regular 8-hour shift per week as a hospital employee. Nursing education at KU had become a recognizable academic program complete with an extensive clinical component in place of the old apprenticeship model that had held for decades from the founding of the school.
William S. Worley
Adjunct Professor of History
University of Missouri-Kansas City