Nursing is possibly the only profession for which programs leading to the exact same professional qualification are offered both at the degree level (by universities) and at the diploma level (by community colleges). Graduates of both institutions write the same exam to qualify for practice as an RN.
Besides being somewhat bizarre, this situation may be unstable because of certain pressures toward change, including: (a) the increasing competitive advantage of the degree holder in the job market making the diploma a less desirable qualification; (b) changes in the work role of nurses and demands on the profession resulting from advances in technology, changing demographics, and changes in health care delivery; and (c) the strong consensus within the profession that the degree should be a requirement for entry to practice. In the 1980s, most groups representing the profession, such as the Registered Nurses Association of Ontario and the Canadian Nurses Association, endorsed the baccalaureate as entry to practice.
The entry to practice position of these organizations would have major implications for approaches to nursing education. At the most general level, there are three options for corresponding reform of nursing education: (i) transferring all nursing programs to universities; (ii) giving the CAATs the authority to grant degrees in nursing; or (iii) developing integrated programs in which, while the degree is awarded by a university, components of the education are provided by both CAATs and universities.
A number of serious practical problems are associated with the first option, e.g. possibly having to build new facilities in universities while some existing facilities in CAATs might become idle; redundancy of CAAT staff; reduction in geographic accessibility; and likely increase in operating costs. Also there would be questions about possible narrowing of admissions criteria, and whether universities could or would accommodate the numbers of students that would be needed-even if there is some reduction in the number of nurses needed.
Practical problems with the second option, giving the CAATs the authority to award degrees in nursing, are whether the same kind of labour market discrimination as exists already between degree and diploma holders would persist as well as discrimination in regard to graduate school admission. But the major obstacle would be the historic tradition in Ontario of strictly confining the authority to grant degrees to a limited number of universities, and the fear that if the CAATs got the authority to grant degrees in one program area it would proliferate to other areas, undermining their primary role.
The drawbacks of the first two options make the third one, that of integrated programs between a CAAT and a university, the most attractive, if not the only feasible approach for achieving the entry to practice goal. The road to achieving integrated programs is, however, not an easy one. For one thing, the intensity of inter-institutional collaboration that is needed is difficult enough to develop in the best of circumstance, but the history of colleges and universities in Ontario working in two solitudes is difficult to reverse. In addition, though probably easiest to work out in a smaller community which has one CAAT and one university, collaborative arrangements would probably need to be developed on a regional or provincial basis to ensure accessibility and equity and allow for necessary mobility in professional practice and professional development.
As well, provincial government support would surely be needed to effect such a scale and depth of inter-sector collaboration, for example in facilitating the necessary flexibility in the funding formulae for the two sectors. But provincial government policy for several years has been opposed to the degree for entry to practice, and thus it could be expected to be opposed to any change in educational structures which would support the entry to practice concept.
During the past several years there have been some significant developments regarding the relationship between universities and CAATs in general, contributing importantly to the context for improving inter-sectoral collaboration in nursing education. The initial catalyst for these developments was Vision 2000 (Ontario, 1990), the first major review of the mandate of the CAATs, initiated in 1988, its final report published in 1990. After nearly a quarter century of almost total separation between CAATs and universities, Vision 2000 made collaboration between the two sectors one of its two major thrusts (the other being accreditation and standards). The final report contained several recommendations aimed to provide greater opportunity for graduates of CAAT occupational programs to complete related degrees at Ontario universities and to facilitate joint programs in which students would do academic work concurrently in both types of institutions.
These recommendations were referred to a Task Force on Advanced Training, established in December, 1991. In its final report, entitled No Dead Ends, published in 1993, this Task Force made recommendations similar to those of Vision 2000, including affirming the importance of partnerships between CAATs and universities; calling for the elimination of barriers to inter-sectoral transfer; and urging the establishment of a new provincial institute which could award degrees for appropriate combinations of CAAT and university students.
The situation for which both Vision 2000 and the Task Force on Advanced Training were proposing reforms was one in which the number of students graduating from a CAAT and moving on to a university constituted less than 0.7% of enrollment in postsecondary programs, compared to something in excess of 10% in British Columbia. It was a situation in which, as recently as January, 1992, the simple action of CAAT and university presidents sitting down together was heralded in the media (“Historic Meeting Opens Doors Between Colleges and Universities”). A study done for Vision 2000 in 1988 identified only 27 formal program linkage arrangements between Ontario CAATs and universities, eight of which were with universities in the United States (Marshall, 1989). Only four of the 27 involved concurrent programs as opposed to transfer arrangements. Three of the transfer arrangements were in nursing, one with an American university.
Although the Government has yet to respond formally to the recommendations in No Dead Ends, it has taken several actions which indicate its commitment to the idea of increased collaboration between CAATs and universities. In 1992, as part of its agenda for restructuring postsecondary education in Ontario in order to make it more efficient, the Government indicated that it wanted to encourage more partnerships between colleges and universities. Nothing in public policy indicates commitment like incentive funding, and with regard to the Transitional Assistance Fund that was established to help postsecondary institutions economize on costs and address pressing needs, it was announced that a particular priority was to be given to projects involving both universities and colleges.
To take two other recent examples of Government support for CAAT-university collaboration: (i) the Ministry of Education and Training announced that it was funding the publication of a credit transfer guide for students who want to move between the two postsecondary sectors; and (ii) Seneca College received funding from the government to build an additional campus right at York University to serve an area many of whose residents had strongly opposed the university site because they felt it would not be sufficiently accessible to low-income earners and immigrants in the vicinity. In choosing a university site over the opposition of many of its core constituents, the government made a strong statement about the value that it attaches to CAAT-university collaboration.
Thus far, nursing has not been a leader in the development of collaborative programming arrangements between CAATs and universities. Data compiled by the Association of Colleges of Applied Arts and Technology in Ontario (ACAATO) in 1993 identified 230 articulation arrangements between CAATs and universities, 90 of which were with out of province-mainly American-universities. Of the 140 arrangements with Ontario universities, 11 were in nursing; and of the 17 that provided for concurrent activity in both sectors, only one was in nursing.
Within the past two years, however, there has been considerable study and discussion of collaborative arrangements between colleges and universities in nursing. In the competition for Transition Assistance Funding for postsecondary education referred to earlier, numerous joint college-university proposals for nursing education were submitted, and two projects were funded. In one, Laurentian University, The University of Western Ontario, Cambrian College and Fanshawe College received $400,000 for a Joint Nursing Articulation Project (JNAP) which was intended to develop “a system-wide process for linking college and university nursing programs”. The other involved a $60,000 grant for Queen's University to collaborate with Loyalist, St. Lawrence, and Sir Sandford Fleming Colleges in improving access and transferability between diploma and degree study.
In its advisory memorandum on Transition Assistance Funding, the Ontario Council on University Affairs, the agency responsible for reviewing proposals from the university side, stated that certain types of initiatives to reform nursing education were out of bounds. Council noted that numerous proposals which would have an impact on nursing were received, but it was “concerned that the integration of college and university nursing programs in the manner proposed in some institutions may have the unanticipated effect of leading to redundancy for the community college diploma stream in the future”, and it was not prepared to fund proposals of “this nature” (OCUA, 1993: 212). In other words, Transition Assistance Funding could not be used to underwrite the groundwork for something that is presently contrary to government policy in Ontario, i.e. helping to make the degree become the only postsecondary credential for the RN.
This was, however, precisely the suggestion which the JNAP put out for discussion in its August, 1993 Green Paper. It proposed that diploma programs be phased out beginning in September, 1994, and that nursing education would subsequently consist of newly designed four year baccalaureate programs which would “capitalize on the strengths and resources (human and material) of both the colleges and universities”. I take this to mean that the content of the new baccalaureate programs would be provided jointly by the CAATs and the universities, consistent with what I referred to earlier as the integrated model. It was suggested further that the planning for this restructuring of nursing education, which “would embrace the best characteristics of the current two systems without loss of their valuable qualities”, should be done on a province-wide basis.
In its report, the JNAP team seemed to retreat slightly from the position taken in the Green Paper (JNAP, 1994). The thrust of the recommendations in the report is on making improvements in credit transfer and accessibility to degree programs within the current system. Only after those recommendations is there one calling for planning for collaborative programs which would utilize the resources of both CAATs and universities “toward the goal of a single preparation for practice as a registered nurse”. It is suggested that this planning should occur on a regional basis and involve faculty as well as representatives of nursing practice, the community, alumnae, and students. The JNAP report also showed that Ontario lags behind several provinces in developing the arrangements whereby it may be possible for most new entrants to nursing to obtain a degree.
About the same time that the report of the JNAP came out, a group which seemingly is most central to the future of nursing education issued a statement which enunciated a vision of nursing education that seems to me to be very close to that of the JNAP. The group to which I am referring is the Provincial Steering Committee (PSC) of the CAATs Nursing Programs and the Council of University Programs in Nursing. Its statement on “Education of the Nurse of the Future” (February, 1994) says that “[t]here will be one educational system for nurses with programs developed and implemented on a regional basis”. Further, this system will be based on “the concept of multiple points of entry in accordance with educational and experiential backgrounds; and the attainment of a baccalaureate for entry to practice as an RN”. The diploma would persist only as a credential for an RPN.
Though the JNAP report and the PSC statement are couched in different language and differ in some respects, they offer similar visions of nursing education in which the CAATs provide a valuable component of the training in a program which ultimately leads to a degree. Simultaneously with the preparation of these documents, discussions have been under way among at least three CAATs and their respective nearby universities aimed at producing the arrangements for integrated programs in nursing.
If, as I suggested earlier, nursing has not yet been a leader in the development of collaborative program arrangements between CAATs and universities, that may be only because of the magnitude of the goal in nursing education-and it may be about to change. What is at issue in nursing is not just the creation of a joint program here and there, but a reform of professional education of major proportions-something which occurs only rarely in any profession.
It is one thing to advocate the principle of the degree as entry to practice, quite another actually to take the steps required to make this a reality. This may explain why some members of the CAAT nursing community who support the entry to practice reacted so negatively to the JNAP Green Paper. For the CAAT nursing units to have as their main function offering a component of the training in a baccalaureate being awarded by a university, is to place themselves in a potentially quite vulnerable, powerless, and perhaps demoralizing position.
If the role of the CAATs in an integrated baccalaureate nursing program is looked upon as merely that of subcontractor responding to the purchase orders of universities, then not only will the CAATs be disempowered in this area of education, but the integrated program concept will likely fail. For this initiative to be successful, the CAAT nursing community must be given the status of full partner in the design, planning, delivery, and supervision of the integrated nursing program. Within that partnership, each sector would, as both the JNAP and PSC documents say, contribute from its respective areas of strength.
If some are concerned that such a partnership would limit the autonomy of the university, they should remember that the one area in which the autonomy of Ontario universities has always been considerably limited in that of professional programs, particularly in the health sciences. Such limitation on a university's autonomy as might result from genuine collaboration with CAAT sector institutions would be no different in principle from that which is already accepted in regard to collaboration with other universities, for example in regard to provincial review of graduate programs.
Vision 2000 and the Task Force on Advanced Training offered two types of recommendations for closer relationships between CAATs and universities. That involving a reduction of barriers for the student who wishes to transfer to a university after attending a CAAT is the less ambitious of the two, and it appears that considerable advances are being made in this respect across the postsecondary system.
The other type of relationship involves creating the opportunity for students to combine studies in a CAAT with studies in a university in such a way that studies in both sectors mesh together in a coherent manner appropriate for the awarding of a degree. Among other rationales for this proposal-which are detailed in these two reports-it was suggested that this might be the most effective way to implement polytechnic education in Ontario. Thus far, there have been no moves toward the second type of CAAT-university collaboration except for the attention which the integrated program concept has been receiving among nursing educators. If any progress is to be made generally in regard to these recommendations of Vision 2000 and the Task Force on Advanced Training, there is no better place to start than in the field of nursing.
ACAATO. [1993, May]. Postsecondary Programs. College-University/Institute Transfer Guide: Draft. Toronto: Association of Colleges of Applied Arts and Technology in Ontario.
Marshall, Robert Alexander. . College-University Transfer Arrangement Existing in Ontario (Questionnaire Results). A Background paper prepared for Vision 2000. Toronto: Ontario Council of Regents.
Joint Nursing Articulation Project. [1993, August]. Green Paper. Sudbury: School of Nursing, Laurentian University.
Joint Nursing Articulation Project. [1994, March]. The Report.
OCUA. [1993, September]. Nineteenth Annual Report, 1992-93. Toronto: Ontario Council on University Affairs.
Ontario. . Vision 2000: Quality and Opportunity. Toronto: Ministry of Colleges and Universities.
Ontario. [1993, April]. No Dead Ends. Toronto: Task Force on Advanced Training.
Provincial Steering Committee. [1994, February]. Education of the Nurse of the Future. Position Statement by the Provincial Steering Committee of the Colleges of Applied Arts and Technology Nursing Programs and the Council of Ontario University Programs in Nursing.
Michael L. Skolnik is a Professor in the Higher Education Group at the Ontario Institute for Studies in Education. This article builds upon a previous paper which was widely circulated, entitled “Some Unthinkable Options for Implementing the Entry to Practice Proposal for Nursing in Ontario - A View from Outside the Profession.” Toronto: Higher Education Group, OISE, November, 1988.