Just Released - Nursing Leadership 27.2

Volume XX, Number X • 2011 www.nursingleadership.netVolume 27, Number 2 • 2014 www.nursingleadership.net
Canadian Journal of Nursing Leadership
Nursing
LeadershipLeadership in Nursing Management, Practice, Education & Research
Baccalaureate Nursing Education: Has It Delivered?
A Retrospective Critique 27
Commentary: Future Directions for Nursing Education 35
Boundary Spanning by Nurse Managers: Effects of Managers’
Characteristics and Scope of Responsibility on Teamwork 42
Commuter Migration: Work Environment Factors Influencing Nurses’
Decisions Regarding Choice of Employment 56
Politics • Policy • Theory • Innovation
SPECIAL FOCUS ON
THE FUTURE
OF NURSING
p.14

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EDITORIAL 1
From the Editor-in-Chief
Creativity Core to the rEvolution of Education
“The challenge now is to transform education systems into something better suited to
the real needs of the 21st century.At the heart of this transformation there has to be a
radically different view of human intelligence and of creativity”(Robinson 2011: p.14)
Although nursing education in Canada has undergone marked changes over the last
50 years,with the advent of technology mediated approaches to teaching,learning,
and healthcare delivery,it essential and of some urgency to dramatically rethink the
foci and methods of undergraduate nursing education now.Whether health promo-
tion,maintenance or restoration,the healthcare needs of a predominantly older
Canadian demographic have shifted.Similarly the locus and modes of care delivery
are continuing to devolve from the bastions of hospital care to home and community-
based care supported by inter-professional teams of clinicians with ever broadening
scopes of practice.Thus nurses’work and the nature of practice environments are
rapidly evolving such that the requisite skills and knowledge of practitioners may be
sadly lacking in our new graduates.Not to mention that the undergraduate student
of today is inclined to want to learn in ways different from the predominant endur-
ing methods provisioned by our academic institutions.As the rethinking of nursing
education unfolds,the creativity element of leadership will be essential to our collec-
tive success.

2 Nursing Leadership Volume 27 Number 2 • 2014
In previous issues of CJNL,authors have highlighted the key recommendations arising
from the CNA’s National Expert Commission (Villeneuve and Mildon,2013a; 2013b).
In relation to nursing education,the commission specifically underscored the impor-
tance of collaboration among professional associations,educators,scientists,unions,
and employers to reach“consensus on the scientific knowledge,education,competen-
cies and skill sets demanded of effective 21st century registered nurses.”They noted
that“curricula are out of date and out of step with the transformations”that lay ahead
in healthcare,and issued a call to make radical changes in healthcare education includ-
ing new topics and teaching methods (CNA 2012: 45).Another call to action which is
inextricably connected to any revamp of content and techniques is the need to escalate
the use of technology – in their words:“Learning to take full advantage of technology
should be just as important a part of education and employer orientation as learning
about medications”(2012: 46).
Subsequent to the release of the commission’s report was the constitution of a think
tank to address the future of nursing education in Canada.A report of those delibera-
tions has also been tabled (MacMillan 2013) and the key directives synthesized for our
readership (MacMillan and Gurnham 2013).Of particular note was a clarion call for
a national review of nursing education,the likes of which has not been undertaken
since 1965.In this issue,Baker provides us with a synopsis of some significant mile-
stones in Canadian nursing education including the outcomes of previous landmark
studies.Pilj-Zeiber and colleagues provide an historical perspective on what the shift
to baccalaureate education has meant for contemporary nursing practice in Canada.
They posit that debates about the value of education versus service,professional versus
vocational identity,and theoretical versus practical knowledge persist in the midst of
concerns regarding the misalignment of education and practice.
Regardless of these debates,let’s be sure not to exclude the target of our intentions in
the discussion.We are seeing a new kind of learner with different needs,capabilities
and resources; our students are products of a technology-mediated society and as such
have very different expectations.Days of the“sage on the stage”are no longer accept-
able; being the“guide on the side”is the order of the day (King 1993).In rethinking
nursing education it is equally essential to challenge pedagogical techniques and
traditions in order to be effective and responsive to the needs of the new generation
of student nurse.Personally the experience of trying new methods in the classroom
and online (e.g.,flipped classroom,wikis,MOOCs,Peer Scholar ® – these are yours’
to explore) can be profoundly rewarding if not an opportunity to overturn one’s
entrenched views of teaching and learning.While not at all discomfited by technology,
presently designing an online graduate course on leadership and administration has

3
presented this academic with some interesting possibilities.While lamenting the loss
of“the classroom”on the one hand,the demand for creativity in designing an online
learning space that incorporates effective elements of student engagement and creates
a community of learning is kind of fun.The old dog can learn new tricks.
As Sir Ken Robinson (2011) wrote:“the role of a creative leader is not to have all the
ideas; it’s to create a culture where everyone can have ideas and feel that they’re valued.”
Let’s get creative together!

Lynn M. Nagle, RN, PhD
Editor-in-Chief
References
Canadian Nurses Association (CNA), 2012. A Nursing Call to Action. Report of the National Expert
Commission. Accessed June 10, 2014 at: www.cna-aiic.ca/expertcommission.
King, A. 1993.“Sage on the Stage to Guide on the Side.” College Teaching 41: 30-35.
MacMillan, K. (Ed.) 2013. Proceedings of a Think Tank on the Future of Undergraduate Nursing
Education in Canada. Halifax: Dalhousie University School of Nursing.
MacMillan, K. and M. Gurnham. 2013.“Leaders Hold an Invitational Think Tank on Undergraduate
Nursing Education.” Nursing Leadership 26(2): 25-28. doi: 10.12927/cjnl.2013.23304.
Robinson, Sir K. 2011. Out of our Minds: Learning to be Creative. Capstone Publishing: West Sussex, UK.
Villeneuve, M. and B. Mildon. 2013a.“Better Health, Better Care, Better Value: National Expert
Commission, Part 1.” Nursing Leadership 26(1): 20-23. doi: 10.12927/cjnl.2013.23452.
Villeneuve, M. and B. Mildon. 2013b.“Better Health, Better Care, Better Value: National Expert
Commission, Part 2.” Nursing Leadership 26(2): 19-24. doi:10.12927/cjnl.2013.23451.

special focus on
nursing in public health
Call for Papers/Abstracts
Nurses are taking on increasingly important leadership
roles in the public health system. The Canadian Journal
of Nursing Leadership will publish a focused issue
devoted specifically to the challenges and opportunities
for nurses in the public health sector.
we are looking of papers that focus on:
• Unique leadership challenges in Public Health
• Demonstrations of research, case studies
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• Innovations (e.g., the use of technology)
• Current and emerging policy issues
Prospective authors are invited to submit a 200-word abstract in advance of
their manuscripts.
Abstracts should be sent to:
Dianne Foster-Kent, Editorial Director: dkent@longwoods.com
Canadian Journal of Nursing Leadership
Nursing
LeadershipLeadership in Nursing Management, Practice, Education Research

Volume 27 • Number 2 • 2014
EDITOR-IN-CHIEF
Lynn M. Nagle, RN, PhD
Assistant Professor
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
EDITOR, POLICY AND INNOVATION
Michael J. Villeneuve, RN, MSc
Lecturer and Associate Graduate Faculty
Lawrence S. Bloomberg Faculty of Nursing,
Principal, Michael Villeneuve Associates
Mountain, ON
EDITOR, PRACTICE
Patricia Petryshen, RN, PhD
Chief Executive Officer
Assessment Strategies Inc.
Ottawa, ON
EDITOR, RESEARCH
Greta G. Cummings RN, PhD
CIHR New Investigator
AHFMR Population Health Investigator
Professor, Faculty of Nursing,
University of Alberta
BOOK EDITOR
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Partner, donnerwheeler
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EDITOR EMERITUS
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Professor Emeritus Dean Emeritus
Lawrence S. Bloomberg Faculty of Nursing
Executive Lead, Health Outcomes for Better
Information Care
Ontario Ministry of Health LTC
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Vice President and Chief Nursing Executive
Hamilton Health Sciences Centre
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Director of Nursing and CNO,
Montreal General Hospital
Montreal, QC
Rhonda Seidman-Carlson, RN, MN
Vice President Interprofessional Practice and
Chief Nursing Executive
The Scarborough Hospital
Scarborough, ON
Joan Shaver, PhD, RN, FAAN
Dean, College of Nursing
University of Arizona
Tucson, AZ
Linda Silas, RN, BScN
President
Canadian Federation of Nurses Unions
Ottawa, ON
Carol A. Wong, RN, MScN, PhD
Assistant Professor
School of Nursing, Faculty of Health Sciences
The University of Western Ontario
London, ON
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In This Issue
Volume 27 • Number 2 • 2014
1 Editorial
ACEN UPDATE
8 Nurses: Leading Change One Day at a Time
Katherine Chubbs
There has been enormous progress in nursing, and that progress did not come without change.
Nurses have two choices: to be a part of developing and leading the change, or to have change
happen to them.
EMERGING LEADERS
10 Critical Appraisal through a New Lens
L. Kathleen Stevens, E. Darlene Ricketts and Jill E.E. Bruneau
Critical appraisal is a shift that nurses require. But how can they develop it?
SPECIAL FOCUS ON THE FUTURE OF NURSING
14 Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age
Tim Porter-O’Grady
Nursing is on the verge of a major shift in both its work and its value due to increasing pressure
to move out of acute-care hospitals and into the community; and the influence of digitization in
how nurses are able to provide care.
21 Commentary: Nursing Must Learn to Adapt
Roger Watson
When examining the qualities required to meet the future, it is clear that if nursing does not learn
and adapt, it will not survive; if it does not survive and begin to shape its environment, then it
will become irrelevant.
24 Commentary: Nurses’ Positive Impact Across the Continuum
Rob Fraser
Leaders need to look far ahead, setting a course that “excites and engages” others in improving
nurses’ positive impact on health, throughout life and at the time of death.
LEADERSHIP PERSPECTIVE
27 Baccalaureate Nursing Education: Has It Delivered? A Retrospective
Critique
Em M. Pijl-Zieber, Sonya Grypma and Sylvia Barton
The authors challenge the current nursing system and call for a nationwide curriculum review to
help the profession adapt to the changing needs of the Canadian healthcare system.
35 Commentary: Future Directions for Nursing Education
Cynthia Baker
Critical reflection on the introduction of baccalaureate education as the entry-to-practice require-
ment in Canada is timely. Efforts to chart future directions for nursing education must take into
account long-standing issues from the past.

In This Issue
Published by the Academy of Canadian Executive Nurses/L'Académie des
Chefs de Direction en Soins Infirmiers and Longwoods Publishing Corporation
7
Indicates Peer-review
NURSING RESEARCH
42 Boundary Spanning by Nurse Managers: Effects of Managers’
Characteristics and Scope of Responsibility on Teamwork
Raquel M. Meyer, Linda O’Brien-Pallas, Diane Doran, David Streiner, Mary Ferguson-
Paré and Christine Duffield
Increasing role complexity has intensified the work of managers in supporting healthcare
teams. This study examined the influence of front-line managers’ characteristics and scope of
responsibility in teamwork.
56 Commuter Migration: Work Environment Factors Influencing Nurses’
Decisions Regarding Choice of Employment
D. Rajacich, M. Freeman, M. Armstrong-Stassen, S. Cameron and B. Wolfe
This mixed-methods research examined factors influencing registered nurses’ decisions to work
in their home country, Canada, or to commute daily to a nursing position in the United States.
BOOK REVIEW
68 Nursing Leadership from the Outside In
Reviewed by Pam Hubley
This book is intended to help nurses develop their leadership potential using insights, stories,
lessons learned and practical tips offered up by a wide range of individuals who have worked
with nurses, experienced nursing care or relied on nursing leadership to advance their goals.
Perspectives from business leaders, physician CEOs, professional association directors,
academic heads and politicians are shared with honesty and personal insight.
4 Special Focus on Nursing in Public Health – Call for Papers/Abstracts
40 Call for Reviewers
41 Thank you to our reviewers

8
Nurses: Leading Change
One Day at a Time
Katherine Chubbs, RN, MHS
Vice President and Chief Nursing Officer,
Eastern Health, NL
President, Academy of Canadian Executive Nurses
Chair, Canadian College of Health Leaders,
NL Chapter
I know that sometimes it feels as though we stay status quo day after day or year
after year, but actually so much has changed in nursing as a profession.
I occasionally hear a nurse say,“we tried that before and it did not work,” or “been
there, done that,” but my thoughts always come back to “why?”Was it because the
environment was not ready, the nurses were not ready, the patients or clients were
not ready?
There has been enormous progress in nursing, and that progress did not come
without change. The way I see it, we have two choices: to be a part of develop-
ing and leading the change, or to have change happen to us. I can think of many
scenarios where change has happened to me in my career: changing scope of prac-
tice, changing workplace, changing position, changing organization and on and
on. But in my experience, which is like that of many others, it is best to participate
in making that change happen.
Nurses have been leading change and innovation likely for as long as the
profession has existed. For example, some of you may not know that Florence
Nightingale is credited with inventing the polar graph (Reference.com 2014).
Not all nurses have to be inventors, but we do want our nurses to be involved in
creating organizations that we can be proud to say deliver excellent evidence-
based, high-quality care in safe environments.
Labour is a meaningful experience. Having to work harder at something makes
it more meaningful – this is known as the IKEA effect (Norton 2009). The IKEA
effect also demonstrates a limitation, namely, that labour leads to higher value
only when the labour is fruitful (Norton 2009). Many nurses feel that they have to
work harder now than ever before. Despite this, they continue to bring new ideas
ACEN UPDATE

9Nurses: Leading Change One Day at a Time
to the forefront and be involved. We know that when nurses are involved in the
creation of something, they value it more.
A survey by researchers at Harvard University of nearly 600 senior execu-
tives identified engagement as the third highest success factor in their business,
coming just slightly behind a high level of customer service (in our world, how
we service our patients, clients, residents and their significant others) and effec-
tive communication (Harvard Business Review Analytic Services 2013). Business
leaders recognize that an engaged workforce leads to innovation, productivity and
bottom-line performance (Harvard Business Review Analytic Services 2013).
There is a valuable cycle evolving here. Nurses need to be involved in decision-
making and change to make their work meaningful; meaningful work creates
engagement; engagement increases innovation, productivity and performance;
innovation leads to change.
As senior nursing leaders, we need to make this our approach. How can we help
nurses to be involved? Encourage them to volunteer for any opportunities they
see to improve service, and to speak up when they think change is needed. Inspire
them to challenge the status quo and ask to try new things. We have to be open to
new ideas and ways of doing our work. If something doesn’t work, then we can try
something else.
As nurses, we must love our work. We will never give it our best if we don’t. As
nurses, we must be at the forefront of change and innovation. We each have the
power to influence our environments to make them more like what we want –
more what we will love. In fact, I would say we all have a responsibility to do that.
Lastly, as nurses, we have knowledge. We are highly educated, skilled leaders who
have the power to do great things.
At nearly 300,000 strong, Canadian nurses will lead our organizations to the
places they need to be.
In the words of John Ruskin,“When love and skill work together, expect a
masterpiece.”
References
Harvard Business Review Analytic Services. 2013. The Impact of Employee Engagement on
Performance. Retrieved May 13, 2014. http://static.hbr.org/hbrg-main/resources/pdfs/comm/
achievers/hbr_achievers_report_sep13.pdf.
Norton, M.I. 2009. The IKEA Effect: When Labor Leads to Love. Retrieved May 13, 2014. http://hbr.
org/web/2009/hbr-list/ikea-effect-when-labor-leads-to-love.
Reference.com. 2014. What Did Florence Nightingale Invent? Retrieved May 13, 2014. http://
answers.reference.com/wellness/misc/what_did_florence_nightingale_invent.

Many websites, nursing education sessions and journal articles stress the impor-
tance of critical appraisal of research for evidence-informed decision-making.
Prior to starting our doctoral program, we assumed that because a study was
published, it had strong evidence. In reading research reports we, like others, had
a tendency to focus on results and sample size, taking what was presented more or
less as fact or at face value. We often gave all evidence equal weight regardless of
the strength of the study design or the internal validity of the methods. After all,
these published articles had been peer reviewed! However, we have now learned
that astute critical appraisal requires the ability to critically appraise the research
methodology, the quality of the evidence, the applicability to clinical practice and
the opportunities to improve patient care and outcomes. Furthermore, it is also
important to be able to assess the quality of a body of evidence in addition to the
quality and limitations of individual studies. So, critical appraisal is a skill that
nurses require. But how can we develop it?
Our Epiphany about Critical Appraisal
In our undergraduate nursing education, we learned that to develop any skill,
practice is required. As nurses, we understand skill development. To learn how to
take a patient’s blood pressure (BP), we practised possibly a hundred times
before transferring this knowledge and skill to the clinical setting. Based on our
Critical Appraisal through a New Lens
L. Kathleen Stevens, RN, MN
Doctoral student, Memorial University School of Nursing, St. John’s, NL
E. Darlene Ricketts, RN, MPH
Jill E.E. Bruneau, NP, MHSc

11EMERGING LEADERS
assessment or appraisal of a patient’s BP, important clinical decisions were made
for that patient. Through all these BP assessments we learned the nuances and
variations of the sounds of the systolic and diastolic pressures. By practising, we
developed confidence to transfer this skill to the clinical area. However, even when
we arrived in the clinical setting, our instructor accompanied us to guide our
assessments until we were competent to work independently.
Is this what happens with the skill of critical appraisal of research evidence?
Important clinical decisions, such as choice of dressings to promote optimal
wound healing, are also made for clients based on the assessment and appraisal
of research. However, the preparation that we received about evaluating research
evidence is dissimilar to the preparation we received for learning how to do a
BP. Undergraduate students are often required to find a minimum number of
research articles in preparation for clinical work or for writing a paper, but usually
they do not critique the methods used in these research reports. Students often do
not distinguish between a literature review and a research study. Even after they
have completed a research methods course, the key limitations that students
identify often focus on sample size, validity and reliability of instruments, and
generalizability, with equal weight given to all types of study designs and study
quality. Lack of consistent use of critical appraisal tools may contribute to such
superficial appraisals.
As nursing students, we were taught that research is vital to nursing practice, but
unlike learning to take a BP, we did not practise critical appraisal of research stud-
ies a hundred times. As well, we had no opportunity to develop the confidence
to transfer these skills to the clinical setting. The incongruity is that we knew
evidenced-informed decision-making was vital to delivering high-quality care, but
we did not fully appreciate the depth of critical appraisal required to make a thor-
ough assessment. This situation would be similar to knowing that assessing a BP
was vital for patient care but not being able to transfer and apply that knowledge
to practice.
As doctoral students in a research methods course, we had the opportunity to
study critical appraisal, practise it and receive feedback. This experience led to
an epiphany about the complexity of critical appraisal as a systematic skill to be
developed and enhanced over time. Our intention is not to criticize undergradu-
ate education, but to look at critical appraisal through a new lens and to explore
the implications of this epiphany for nursing management, education and practice.

Critical Appraisal Skills in the Practice Setting: Who Needs Them?
It is easy to understand why researchers need to appraise research evidence criti-
cally in order to develop research proposals and interpret their own research find-
ings. It is less easy to understand why those in practice need good critical appraisal
skills. However, we believe that they do! Nurses in practice, at all levels, need the
same critical appraisal skills as researchers, although they may apply them in
different contexts. For example, programs and policies need to be informed by
the best evidence, and this can occur only if critical appraisal is conducted. It
is therefore especially important that nurses who serve on policy and proce-
dure committees be able to find, critically appraise and synthesize the available
evidence to inform policy and practice recommendations.
Others in practice frequently consult the literature for different reasons than
policy and procedure committee members. All nurses read literature to keep up to
date about their particular practice area. Managers, clinical educators and those
in specialist roles also look at literature to identify new approaches to address
concerns or to prepare an educational session for nurses, patients or patients’
families. Being able to assess the validity and value of individual research stud-
ies and literature reviews will help ensure that their own recommendations are
informed by evidence. Staff nurses may read fewer research reports than manag-
ers and educators, and they may read them for a different purpose, but critical
appraisal skills will facilitate their questioning and validation of their practice.
Implications for Nursing Practice, Education and Partnerships
It is crucial that those in leadership positions in nursing academia address the
development of critical appraisal skills in nursing students, because this is where
future nurses and nurse leaders are first introduced to research and research utili-
zation. At the same time, educational initiatives in the practice setting should be
undertaken to promote skill development in practising nurses, because they likely
have the same understanding of critical appraisal that we had prior to starting
our doctoral program. Journal clubs may help nurses on the front line feel better
prepared to appraise research, participate in committee work and help translate
evidence into practice, as well as stimulate them to discuss and question practice.
Now is the time for nursing leaders to find opportunities to create environments
that promote learning in critical appraisal, particularly in areas where nurses
would most utilize these skills. For example, those who work on policy and
procedure committees, or who rely heavily on the literature in their work, may
need more focused education and support related to critical appraisal.

13Critical Appraisal through a New Lens
Collaboration among leaders in nursing education, practice and research, as well
as with other health professions, would be beneficial. Using similar approaches in
these different areas of nursing will result in continuity and consistency for nurses
as they continue to build and apply their critical appraisal skills. Furthermore,
collaborative inter-professional educational initiatives will mean that research
expertise from all involved disciplines can be shared and enhanced. If nurses
receive the same education as other health professionals, they will learn to use
a common language in critical appraisal and in promoting evidence-informed
recommendations.
So What’s Next?
We need to change the system so that future new nurses will have a stronger skill
set and the work environment will help them strengthen and apply those skills.
But we also need to play catch-up. Nurse leaders must make a special effort to
address the present situation in both education and practice, and to bring criti-
cal appraisal skills to the essential level required to achieve evidenced-informed
decision-making and practice. Building this expertise can help improve outcomes
for patients, nurses and the populations they serve. Let’s get moving!
Acknowledgements
The authors would like to thank Dr. Donna Moralejo for triggering our epiphany
about critical appraisal and for her valuable assistance with this paper.

14
Leading the Revolution in Nursing
Practice: Advancing Health in the
Digital Age
Tim Porter-O’Grady, DM, EdD, APRN, FAAN
Senior Partner, Health Systems, TPOG Associates, Atlanta, GA
Professor of Practice, College of Nursing and Health Innovation ASU, Phoenix, AZ
Clinical Professor, Leadership Scholar, College of Nursing OSU, Columbus, OH
Adjunct Professor, School of Nursing, Emory University, Atlanta, GA
Nursing is on the verge of a major shift in both its work and its value. Since the
time of Nightingale, nurses have been caring for the sick and have developed a
growing presence in the acute care environment, where the majority of nurses
practise today (McDonald 2010). Yet, the very foundations of nursing are
grounded in the community, and nursing is fundamentally driven by the urge
to advance and maintain health and prevent illness (Dossey 2005). While many
nurses practise in just such pursuits, the majority are employed by hospitals and
health systems in the care of the sick. The medical model, which has dominated
Western medicine for the majority of the 20th century, has consumed much of
the nursing profession’s energies and focus (Goldsmith 1993; Haven 1869; Sarma
et al. 2012). Medicine’s ability to advance treatment modalities and surgical
interventions, and to refine drug therapies, has reinforced a predominating
tertiary model of medical services and care that has ultimately focused on late-
stage, late-engagement interventions and care services (Wilson et al. 2012).
The problem with this approach, however, is that the net aggregate health of
persons over time has not been substantially improved as a direct result of these
clinical efforts alone (Smith and Institute of Medicine 2012). Indeed, the condi-
tions that create the demand for many interventions have actually accelerated,
with little in place to address them early and effectively before they require more
intensive measures, along with their attendant costs: heart disease, diabetes,
obesity and cancer, among others, keep expanding, with concomitant pressure
on health and fiscal resources. Health effectiveness, sustainability, longevity and
SPECIAL FOCUS ON THE FUTURE OF NURSING

15
quality of life are sacrificed and are the price paid for such a system. This approach
continues to strain social, political and economic capital in a way that simply
cannot be sustained without risking national viability and solvency (Gortmaker et
al. 2011; Porter and Teisberg 2006; Ray 1995).
At the same time, the continuing and deepening impact of digitization in
the contemporary age is changing everything we are and everything we do.
Communication technology mobilizes us in ways that accelerate our portability
and availability to one another in a virtual medium that removes almost all barri-
ers to human communication and interaction (Brooks and Grotz 2010; Horn
2010). Digitization and miniaturization create engineering utility that alters our
therapeutics, interventions, intensity and outcomes in almost unimaginable ways.
Genomics, genetics and DNA manipulation promise a whole therapeutic milieu
that foreshadows the decline of hospitals and late-stage interventions for whole
populations of patients and clinical conditions (Gu 2011). All these factors, when
taken together, create a synergy that shifts the social and service construct for
healthcare and creates a new complexity that changes the way in which nurses
practise, how they provide care and where they work.
The New Social Compact
The new social compact that emerges from the convergence of these forces in the
contemporary age is driven by an essential need for accountability and value. In
fact, the conditions of the age call for a real commitment from nursing leaders
(indeed, all health leaders) to establish a direct relationship between nurses’ work
and the impact that work has on the health of those we serve. It is imperative
that the language and structures that represented a “volume-based” approach to
service, care and resource use be eclipsed now by a more robust demonstration of
impact, outcome and value (Kathy Malloch and Timothy Porter-O’Grady 2010a).
The question now is not so much “what did you do?” but more “what difference
did it make?” The notion of whether the work was valuable insofar as it produced,
changed or improved the health and healing experience is now the critical metric
that validates its value and impact. The price of service now must more strongly
reflect the value of that service, not simply its cost. If what we do as nurses merely
feels good or right, or represents a ritual or routine that is no longer relevant, then
it should not be paid for.
In the digital age, the information infrastructure should now reveal just-in-time
information about the veracity and validity of a specific nursing action in a way
that verifies it, challenges it and ultimately changes it in real time. Patients come
to the health system not so much for what it does but instead for what they get
(value). If they don’t get what they were promised or have a right to expect, it
doesn’t matter what was done for them. Nursing practice isn’t inherently valuable
because we do it; it is valuable because it makes a difference in the health and life
Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age

of those we serve. In this era, we must be able to show evidence of a direct cause-
and-effect relationship between what we do and what really happens for patients.
In addition, the health of our populations is not driven by the action of any one
discipline. The essential interface of the clinical efforts of all providers that make
up the partnership of contribution affecting outcome and value is key to effective
health service. The vertical and linear structures within which we have histori-
cally worked are no longer effective in this digital age to successfully provide a
continuum of value-defined services. The earlier we engage people and popula-
tions, the more diverse our service structures must become. Further, early engage-
ment systems must be more localized, decentralized and point-of-service driven
(Stutz 2013). Patients must themselves be drivers and co-participants in decisions
and actions that affect their care. Because most late-stage interventions reflect
inadequate early-stage lifestyle choices, the ability of providers to access persons
“where they live” will be critical to meaningful and sustainable impact. This is
especially true for the sickest minority of persons who drive the majority of the
costs of healthcare. The earlier we can engage these populations, the greater the
economy-of-scale impact we can have on resource use and quality of life. To do
so will require the best efforts and evidence-grounded approaches (Melnyk and
Fineout-Overholt 2012). These will be hammered out in the necessary nego-
tiations between the team of providers and the patient in a concerted effort to
change habits, practices and behaviours honed by consistency, determination
and congruence along the continuum of care. Such an approach creates real-time
modalities that are transferable as they are tested and communicated within the
linked and integrated clinical information system that informs clinical leaders –
also in real time – of their value and affordability.
What Leaders Must Do
Nursing leaders have a huge obligation to broaden nursing awareness of the
significance of this sea-change affecting practice over the next two decades. Nurses
entering practice today will spend the majority of their careers in making these
changes and writing a new script for practice. Time is of the essence, and there is
little that is more relevant work for today’s leaders.
Leaders do not generally live solely in the present. If they do, they are not provid-
ing much leadership. Leaders live in the potential – somewhere between here and
there. True leaders have peered over the horizon, or at least done a good job of
environmental scanning, as they anticipate the future. Leaders spend a good deal
of their time in translational work, helping others understand what it is about
the future that they must be aware of today. In this effort, the leader sets the land-
scape for staff “proaction” – preparation for timely and relevant response (Porter-
O’Grady and Malloch 2008).

17Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age
With this in mind, here are five specific leadership activities that are critical at
this time:
1. Leaders must be able to anticipate and predict the trajectory of changes that will
affect the future of nursing practice. It is increasingly important for leaders to
be able to coalesce effort around critical factors that point towards significant
differences for tomorrow’s healthcare. The convergence of technological, socio-
political and economic changes described above creates the value-driven context
for healthcare providers of the future. If leaders have “kept up” with the trend-
ing circumstances of the time, they should not be surprised by their impacts on
service and care. And neither should their staff, if the leaders have been good
and faithful in translating and applying the change factors to their own clinical
environments and roles.
2. Good leaders read broadly beyond their own field in order to determine what is
transferable, or at least applicable. At least 10% of a leader’s time should be spent
in exploration and the generation of innovation. There is a need for new think-
ing. The leader should be challenging staff with the questions,“What difference
did you make here today? What has changed as a result of what you have done
today? What will you do differently tomorrow as a result of what you discovered
today?”While standardization enables customization, standardization is not an
end; it is merely the ground of practice, the scaffolding, from which nurses reach
to the innovative and the excellent. No one ever standardized themselves to
excellence, but no one ever achieved excellence without having a standard upon
which to construct it.
3. The leader must demonstrate an availability, even vulnerability, to the demand
for growth and change. Recognizing the impact of cellular communication, for
example, and the portability it implies, means the leader doesn’t work to prevent
the young nurse from texting the physician but finds a way to make the action
useful, meaningful, safe and confidential. Staff cannot go anywhere the leader
hasn’t been or is not willing to go. Embracing the journey and the challenges
to personal comfort, security and competence is a sign of great leadership.
The leader works to “set tables” for creative and innovative trans-disciplinary
dialogue about service, partnership, care and the continuum. Making it safe to
“push the walls” of past practice is a role requirement for every leader today.
4. The early stages of any meaningful change involve heavy commitment from the
leader and some degree of deconstruction. Innovation requires taking apart at
least some of the existing reality or circumstances that reflect past practice,
habit, ritual or routine. This often means confronting staff behaviours directly
and engaging them in the “noisy” process of assuming a new way of being or
doing. The natural reaction to this dramatic impact of the early change process
often places leaders in a negative light, compelling them to deal with staff
complaints, blame or other forms of “acting out.” This state is disagreeable

Nursing Leadership Volume 27 Number 2 • 201418
enough in itself to make many leaders reluctant to lead any change. Leaders
must recognize such reactions as normative, incorporate them into the plan for
change and give staff reaction a voice, a medium for expression. This way, the
negative energy associated with change has a place to go; it becomes visible and
useful in identifying various challenges to the change in a way that can be posi-
tively addressed.
5. What change agents bring to thinking about change is important to the relevance
and viability of the change itself. Innovation requires different patterns of think-
ing. Leaders must reflect on change in the context of where it is headed, rather
than from a historic or even contemporary perspective. They need to demon-
strate predictive capacity in a way that can translate into the work of creating a
preferred future. The good leader walks ahead into the change and travels back
to the staff with the story of the journey, sufficient to inform their construc-
tion of the scaffolding and substance necessary to get there. The vision of the
change is the province of the leader; the substance of change is the work of the
staff. The leader creates a context and commitment for a shared vision, while the
staff construct the landscape of the lived vision (Malloch and Porter-O’Grady
2010b).
Living The Social Compact of Nursing
Writing the script for a preferred health future is the obligation of nursing leader-
ship. Our legacy from Florence Nightingale is our professional commitment to
the advancement of people’s health (McDonald 2010). She made it clear on many
occasions that ensuring the health of society was a sacred mandate for the nurse
(Mowbray 2008; O’Malley 1931; Williamson 1999). The profession often gets
captured by its commitments to “doing for” and is just as frequently captured by
the questions of “what” and “how.”We often forget that the fundamental question
that purposes our work as nurses is “why.”After all, our work must be driven by
meaning if it is ever to be a sustainable part of the future health landscape.
We are now at a time when we must demonstrate a stronger link between cause
and effect in practice in an effort to establish a sustaining value for our work
(Schmidt and Brown 2012). As time moves on in the health continuum, nursing
work will need to partner more intensely and fit more tightly with the work of
other disciplines. The intersections between team members are becoming more
critical to the seamless experience of truly effective health service. The essential
effort to link information, practise, quality and affordability in contemporary
health systems will require a goodness of fit among all disciplines in a way that
establishes viability, best practices, and service, social and financial value. Systems
will not be able to support players or partners that cannot distinguish their legiti-
macy, impact and value in the relationship between them and their partners in
service. This legitimacy cannot just be defined; it must instead be demonstrated.

19
Effective teams will need comparability among practitioners in order to achieve
the necessary equity in teams to articulate common ground, mutual contribution
and shared value. Those who cannot demonstrate comparability in conceptualiza-
tion, critical thinking, evidence-based practices, contribution and value will rele-
gate themselves to subsequent or secondary roles in applying the script of clinical
work rather than writing it.
There is no doubt that this is a challenging, transformational time for all in
healthcare that calls leaders to the fullest expression of their role. The ambiguity,
tenuousness and uncertainty of the times bear witness to the need for vision, clar-
ity and meaning. Now leaders must stay grounded in the larger and longer view
of the journey, moving further into the digital age. They must be able to translate
the landscape into language that excites and engages nurses and team members
(including physicians and our other clinical partners) in a way that joins all in
the effort to obtain a truly healthy society rather than simply take care of the sick.
Those we serve have the right to expect no less from us. That, after all, is what they
call us to do.
Correspondence may be directed to: Tim Porter-O’Grady by e-mail at: info@tpogas-
sociates.com or by telephone at: 404-892-8494.
References
Brooks, R. and C. Grotz. 2010.“Implementation of Electronic Medical Records: How Health Care
Providers Are Managing the Challenges of Going Digital.” Journal of Business Economics Research
8(6): 73–85.
Dossey, B.M. 2005. Florence Nightingale Today: Healing, Leadership, Global Action. Silver Spring, MD:
American Nurses Association.
Goldsmith, J. 1993.“Driving the Nitroglycerin Truck: The Relationship between the Hospital and
Physician.” Healthcare Forum Journal 36(2): 36–40.
Gortmaker, S.L., B.A. Swinburn, D. Levy, R. Carter, P.L. Mabry, D.T. Finegood et al. 2011.“Changing
the Future of Obesity: Science, Policy and Action.” Lancet 378(9793): 838–47. doi: 10.1016/S0140-
6736(11)60815-5.
Gu, W. 2011. Gene Discovery for Disease Models. Hoboken, NJ: Wiley.
Haven, E.O. 1869. The Medical Profession. Address delivered to the medical class at the University of
Michigan, March 31, 1869. Ann Arbor, MI: Dr. Chase’s Steam Printing House.
Horn, S. 2010.“Digital Medicine: Health Care in the Internet Era.” Choice 47(10): 2017–18.
Malloch, K. and Porter-O’Grady, T. 2010a. Introduction to Evidence-Based Practice in Nursing and
Health Care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Malloch, K. and Porter-O’Grady, T. 2010b. The Quantum Leader: Applications for the New World of
Work. Boston: Jones Bartlett.
McDonald, L. 2010. Florence Nightingale at First Hand. Waterloo, ON: Wilfrid Laurier University
Press.
Melnyk, B. and E. Fineout-Overholt. 2012. Evidence-Based Practice and Nursing and Healthcare (2nd
ed.). St. Louis: Lippincott Williams Wilkins.
Mowbray, P. 2008. Florence Nightingale and the Viceroys: A Campaign for the Health of the Indian
People. London: Haus.
Leading the Revolution in Nursing Practice: Advancing Health in the Digital Age

O’Malley, I.B. 1931. Florence Nightingale, 1820–1856: A Study of Her Life Down to the End of the
Crimean War. London: T. Butterworth.
Porter-O’Grady, T. and K. Malloch. 2008.“Beyond Myth and Magic: The Future of Evidence-
Based Leadership.” Nursing Administration Quarterly 32(3): 176–87. doi: 10.1097/01.
NAQ.0000325174.30923.b6.
Porter, M. and E. Teisberg, E. 2006. Redefining Health Care: Creating a Value-Based Competition on
Results. Boston: Harvard Business School Press.
Ray, R. 1995.“Controlling America’s Health Care Costs via Health Care Futures.” Health Care
Management Review 20(2): 85–91.
Sarma, S., R.A. Devlin, A. Thind and M.K. Chu. 2012.“Canadian Family Physicians’ Decision to
Collaborate: Age, Period and Cohort Effects.” Social Science Medicine 75(10): 1811–19. doi:
10.1016/j.socscimed.2012.07.028.
Schmidt, N.A. and J.M. Brown. 2012. Evidence-Based Practice for Nurses: Appraisal and Application of
Research (2nd ed.). Sudbury, MA: Jones Bartlett Learning.
Smith, M.D. Institute of Medicine Committee on the Learning Health Care System in America.
2012. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Washington, DC: National Academies Press.
Stutz, L. 2013.“The Evolution of Banner Health’s Case Management Program.” Professional Case
Management 18(3): 138–41. doi: 10.1097/NCM.0b013e31828495b1.
Williamson, L., ed. 1999. Florence Nightingale and the Birth of Professional Nursing. Bristol:
Thoemmes Continuum.
Wilson, A., N. Whitaker and D. Whitford. 2012.“Rising to the Challenge of Health Care Reform with
Entrepreneurial and Intrapreneurial Nursing Initiatives.” Online Journal of Issues in Nursing 17(2): 5.

21
Nursing is changing, nursing is about to change more and – from my United
Kingdom perspective – nursing could even be said to be in crisis (Francis 2013).
Crises, such as the one in the United Kingdom, require solutions, and many
people are working hard on this (Council of Deans of Health 2013; Department
of Health 2014; Nursing and Midwifery Council 2013); however, solving crises
adheres us to the past, nudges us into “it must not happen again” anxiety and
inevitably lowers horizons. Leadership is stultified because leaders are visionar-
ies, and in the face of a crisis, vision becomes blurred – blinded even – by fear of
trying anything new for fear that it will not work. Rather, the inevitable message is
“turn the clock back,” back to a time when all seemed to be well, when nurses were
angels and patients got better. The bureaucrats, managers and administrators live
in the past. Some venture into the “now,” but only leaders see the future and “fear
not to sow” the seeds of change.
Dr. Porter-O’Grady does not fall into the trap that I have already stumbled into:
parochialism. He does not mention a country or an incident. He simply points to
the future and outlines the qualities of the people we will need across the world
to ensure that we make it to the future. It strikes me that if nursing does not learn
and adapt, it will not survive; if it does not survive and begin to shape its environ-
ment, then it will become irrelevant.
Commentary: Nursing Must Learn to Adapt
Roger Watson, RN, PhD
Editor-in-Chief, Journal of Advanced Nursing
University of Hull, UK
COMMENTARY

Global Citizens
Without specifying it, what Dr. Porter-O’Grady is pointing to is the global
health agenda (Jamison et al. 2013) and the seemingly inexorable rise in non-
communicable diseases (NCDs). Even the most prominent and at one time
terrifying spectre of HIV/AIDS, which killed without discrimination and for
which a cure seemed impossible, has been brought under control by both
prevention and cure (with no room for complacency on either count and
notwithstanding the global disparities in access to relevant measures). However,
the list of NCDs is long, global, likely to increase with affluence and, in many
cases, preventable; in most cases, it is manageable. Tertiary care is packed with the
cases that went wrong, were not prevented and could not be managed where the
disease occurs: at home and in the community. Nurses are complicit in this acute
care medical model and, while offering lip-service to care in the community and
the superiority of prevention over cure, the classic image of the nurse remains one
of being uniformed, in hospital and largely waiting for orders.
This model is wholly inadequate to address the global health agenda. Global
health has many definitions that need not distract us. However, there is a tendency
to see global health as being “over there” while, all the time, it is right here – wher-
ever you are – either in your local native population or in that increasing sector
of the population that also used to be “over there” but are now “over here.” I recall
teaching students in Edinburgh, Scotland about sickle-cell anaemia and being told
it was a waste of time; they would never encounter it in their local hospital. How
many of those students now work, if not overseas, in large conurbations where
the immigrant community – often many generations in their adopted country –
harbours the genes for sickle-cell and other rare anaemias? Once again, I make the
mistake that Dr. Porter-O’Grady skillfully avoids – of becoming parochial.
Global Leadership
I travel widely, normally more than 10 countries annually in Europe, North
America, the Far East, Southeast Asia and the Southern Hemisphere. In terms of
Dr. Porter-O’Grady’s vision for leadership, I am heartened that everywhere I go I
am inspired by the people I meet in nursing. These are people at all levels and in
all manner of positions but, it has to be said, many in academic positions. They
espouse and exemplify the very qualities that are required: they see “round the
corner” and “over the horizon”; they are eclectic in their reading; and they are not
afraid to be wrong occasionally and are certainly not afraid to be opposed. I see
other qualities at a more prosaic level: they have a sense of humour and even a
disarming self-deprecation; they are not the people who say “I don’t get Twitter”
or “what’s the point in blogging?” These are the people who have embraced the
new technologies, social media and the myriad platforms through which contact

23
can be maintained and influence exerted. Thankfully, a great many are younger
than I. I have seen such colleagues lose their jobs and be sidelined for their vision,
but I have never seen them give up.
Therefore, there is hope. We have the leaders and we have the vision, but these
need to be amalgamated. Is now the time for more leadership programs, more
conferences and more reports? We may need more leadership training, but it
will not yield solutions; conferences seem almost antediluvian in these days of
“constant conferencing,” and another report may give the reporters a sense of
completion and satisfaction. But most reports are out of date long before they are
published, and most focus on yesterday’s problems with yesteryear’s answers. We
need something more flexible, more alive and something that – instead of report-
ing – continues to comment, continues to provoke and continues to question.
Specifically, I was privileged to be part of the inaugural meeting of the Global
Advisory Panel on the Future of Nursing (GAPFON) in March 2014. Thus far the
proceedings and the agenda are not public, thus avoiding the “what about…?”
trap whereby agenda, membership and solutions are offered by national and inter-
national bodies and individuals terrified that their particular interests and angles
may be omitted. Some of these external interests may well be part of the solution,
but many are already part of the problem. GAPFON may not be the solution, but
we will try hard not to be part of the problem.
References
Council of Deans of Health. 2013. Healthcare Assistant Experience for Pre-Registration Nursing
Students in England. London: Author. Retrieved May 3, 2014. http://www.councilofdeans.org.
uk/wp-content/uploads/2013/05/HCA-Pre-reg-experience-Council-of-Deans-working-paper-
final-20130501.pdf.
Department of Health. 2014. The Government Response to the House of Commons Committee Third
Report of Session 2014-14: After Francis: Making a Difference. London: Author.
Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London:
The Stationery Office. Retrieved May 3, 2014. http://www.midstaffspublicinquiry.com.
Jamison, D.T., L.H. Summers, G. Alleyne, K.J. Arrow, S. Berkley, A. Binagwaho et al. 2013.“Global
Health 2035: A World Converging within a Generation.” The Lancet 382(9908): 1898–955. doi:
10.1016/S0140-6736(13)62105-4.
Nursing and Midwifery Council. 2013. NMC Response to the Francis Report. London: Author.
Retrieved May 3, 2014. http://www.nmc-uk.org/Documents/Francis%20report/NMC%20
response%20to%20the%20Francis%20report%2018%20July.pdf.
Nursing Must Learn to Adapt

Tim Porter-O’Grady’s closing paragraph hits the perfect note. Leaders need to look
far ahead, setting a course that “excites and engages” others in improving nurses’
positive impact on health, throughout life and at the time of death. The only
part I would reframe is his claim that now we are on the verge of change. Society,
technology and knowledge are always changing the way healthcare is practised.
Textbooks and journal articles dating back hundreds of years are filled with
authors crying foul over new devices and methods (Hérisson 1835). Technology
will always disrupt, even if disruption takes time. The digital age only accelerates
the rate of change and is creating more opportunities and awareness of deficien-
cies that require us to transform healthcare and nursing practice. Porter-O’Grady
focuses on what needs to be done, and takes a productive approach by suggesting
nurses lean in to shape our own future. This response will build on his approach,
suggesting activities that could support practice transformation.
Avoid Overplanning
Too often, resources are invested only in studying, planning, writing or meeting
about change. Although these activities have value, not every idea and project
require a high degree of oversight, and highly detailed plans with clearly described
outcomes, before starting. Nurses who see opportunities should take small steps to
test their impact and scale solutions that work.
Commentary: Nurses’ Positive Impact
Across the Continuum
Rob Fraser, MN, RN
Registered Nurse, University Health Network
Consultant, Rob D. Fraser Associates Inc.
Board Member, VON Canada

25Nurses’ Positive Impact Across the Continuum
The nursing process teaches us to assess, plan, intervene and monitor changes.
These are skills that translate into project management and quality improvement,
key activities in change management. However, we can learn from other profes-
sions how to keep projects nimble and adaptive. For example, computer program-
mers develop new tools with agile methodologies and share knowledge using
social technologies, an approach that accelerates the rate of change in their field.
An example of this is Hacking Health, a conference bringing clinicians, developers
and designers together to build a health-related app in one weekend. Some partic-
ipants learn a bit about group work and how hard it is to build a website, while
other groups successfully launch apps or new companies. Nurses need to look for
opportunities to turn ideas into reality, and organizations need to create ways to
let clinicians try out innovations. As Porter-O’Grady points out, nursing leaders
need to bring different groups together, both within our profession and outside it,
and embrace the journey though the unknown.
Support and Learn from Others
Leadership is too often misunderstood as being the smartest individual or best
organization, which creates pressure to pretend to have the perfect solutions by
themselves. Instead of trying to reinvent the wheel, leaders should pay attention
to what is working elsewhere. They should adapt and improve upon previous
work. A good leader listens to everyone’s ideas and always has an appetite to learn.
Change also requires support and followers. Nurses need to support and collabo-
rate with their peers rather than criticize those who push change forward.
Porter-O’Grady suggests reading widely and looking outside healthcare for ideas.
Access to the Internet creates new ways to learn from other professions, organiza-
tions and industries. Massive open online courses take learning beyond reading.
For little or no cost, anyone can participate in courses ranging from healthcare
practice to data analysis. These courses are taught by world-class faculty with
engaging content, media and assignments readily available online through compa-
nies like Coursera. Nurses at all levels can use these resources for new tools for
self-development and to create a learning culture in their workplace.
Be Ready for the Hard Part
Nurses need to be present and participate in difficult organizational discussions
and leadership decision-making. On top of the challenge of developing clinical
skills and knowledge of care delivery, leaders need to be ready to develop fluency
in other areas. Organizational finance, legal risk management and succession
planning are key languages of organizational governance and leaders.

Nurses must be part of the conversations that shape the future of our practice
settings, organizations and healthcare systems. The skills required for this endeav-
our are not more or less valuable than clinical skills. Instead, they are necessary to
see, create and execute positive system transformation. If nurses do not participate
at this level, there is a risk that organizations will cut resources, negatively affect-
ing patients. At the same time, if nurses are making these decisions without neces-
sary skills, organizations may not be sustainable, leaving patients and clinicians
even more vulnerable.
Focus on Impact
The digital age has made it easier to measure impact beyond dollars. Digital
information can be stored, transferred, extracted and analyzed in new ways.
Quantitative and qualitative analysis of information focused on patient, family,
community and societal health are critical. Nurses must expose indicators related
to their work that focus on the patient. The outcomes must clearly demonstrate
better health and better system performance.
Further, we need to become comfortable working with data and exploring the
insights that data can provide. Data ubiquity creates the opportunity to track vital
signs and various health indicators across years rather than shifts. The impact that
nurses and healthcare have on illness and wellness must be better measured, tested
and learned from.
Leaders Must Take the First Step
The nursing profession is full of great ideas, as are many other professions. What
makes a great leader is the ability to take ideas and turn them into reality. Florence
Nightingale may be famous for many reasons, but the reason I admire her is her
ability to apply her ideas and intuition. Writing books, applying statistical model-
ling and tracking, as well as lobbying in Parliament, may all require ideas – but
more importantly, they require action. In order for nursing practice to truly be
transformed, we must take steps to turn ideas into reality. Nurses need to explore
how they can leverage new ideas and tools to improve the health of others.
“Knowing is not enough; we must apply. Willing is not enough; we must do.”
Johann Wolfgang von Goethe
References
Hérisson, J. 1835. The Sphygmometer: An Instrument Which Renders the Action of the Arteries
Apparent to the Eye. London: Longman, Rees, Orme, Brown, Green and Longman.

27
Baccalaureate Nursing Education:
Has It Delivered?
A Retrospective Critique
Em M. Pijl-Zieber, RN, BScN, MEd
PhD Candidate, University of Alberta
Nursing Instructor, University of Lethbridge
Lethbridge, AB
Sonya Grypma, RN, PhD
Professor Dean, School of Nursing
Trinity Western University
Langley, BC
Sylvia Barton, RN, PhD
Associate Professor Associate Dean,
Global Health Faculty of Nursing, University of Alberta
Edmonton, AB
Abstract
Despite political support for the baccalaureate degree as entry to practice,
historical concerns over nursing education – the value of education versus service,
professional versus vocational identity and theoretical versus practical knowledge
– persist. The authors challenge the notion of a “two-tiered” nursing system and
call for a nationwide curriculum review to help the profession adapt to the changing
needs of the Canadian healthcare system.
With the passing of legendary nursing leader Dr. Helen Mussallem in Ottawa on
November 9, 2012 at the age of 97, it seems fitting to pause and reflect on the
changes she and other nursing leaders of her day envisioned and accomplished,
with an eye to what these changes mean for the future of nursing. On the strength
of past leaders’ vision for baccalaureate education for all nurses, the current gener-
ation of Canadian nurses has witnessed dramatic changes in nursing education
– the most remarkable of which is the comprehensive shift from hospital-based
LEADERSHIP PERSPECTIVE

training to university-based liberal arts education, and from primarily acute care–
centred curricula to community health–focused curricula. And yet, not all nurses
and students view these shifts as positive. Today, some nurses and students express
a longing for the “good old days” of hospital-based schools, where students
learned “real” nursing skills and could “hit the ground running” when they gradu-
ated. Others disparage community health content within existing curricula,
preferring instead more acute care content to align with the predominant struc-
ture of healthcare in Canada.
Tensions between Service and Learning Interests: From Hospitals to Universities
The move from hospital schools of nursing to universities traces back to tensions
between service and educational needs that surfaced in hospital training schools
in the 1920s and 1930s. From the opening of the first Canadian hospital-based
diploma school in 1874 (Kirkwood 2005) through the 1930s, when Canada
boasted 330 hospital training schools (Paul and Ross-Kerr 2011), the structure
and function of nurses’ training remained virtually unchanged: hospital schools
used an apprenticeship model of on-the-job training (Bonin 1977; Hermann
2001). In exchange for room and board, uniforms, training and a small stipend,
students provided the primary means of staffing hospitals (Saarinen 2008).
Hospitals desired low-cost service, and young women desired low-cost education;
hospital training provided both.
Amid growing concern about the quality of student training, the Canadian
Nurses Association (CNA) and the Canadian Medical Association jointly funded
a nationwide study on nursing education. The resultant Survey of Nursing
Education in Canada (Weir 1932; also called the “Weir Report”) revealed a lack
of high-quality education, including insufficient classroom instruction and lack
of variety in clinical experience, and expressed grave concern about the ethics of
charging sick patients for the education of nurses. This report recommended that
nurse preparation be transferred from hospital schools into the general educa-
tion system of each province, and funded in a fashion similar to other educational
programs. Weir advised that nurses receive adequate liberal arts, as well as techni-
cal, education at the degree level.
Despite these recommendations, by the 1960s, 95% of Canadian nurses were still
being trained in hospitals (Romyn 1990). During this time, the CNA, sparked by
an interest in accreditation, sponsored a second nationwide survey of nursing
education. Conducted by Dr. Helen Mussallem, the resultant Spotlight on Nursing
Education revealed that only 16% of schools met the criteria for accreditation,
indicating ongoing quality problems at hospital schools of nursing. Mussallem
(1960) recommended that the CNA focus on upgrading nursing education
programs, leading to a report entitled A Path to Quality (Mussallem 1964), which

29Baccalaureate Nursing Education: Has It Delivered? A Retrospective Critique
was intended to prepare a plan for the re-development of basic nursing education
programs within the higher education system. The concurrent Royal Commission
on Health Services (Hall et al. 1965) also underlined the need to overhaul nursing
education.
All three of these reports failed to produce timely changes in nursing education.
The reason for this failure has yet to be analyzed. It is plausible that the failed
uptake was due to the fragmented delivery of nursing education across hundreds
of disconnected hospitals that may have been more concerned about their staff-
ing needs than about the education of nurses, or due to lack of collective political
will among nurses and governing bodies. While college preparation for registered
nurses eventually became the norm in Canada, the realization of the baccalaure-
ate degree as the requirement for entry to practice (BETP), initiated in 1957 and
taken up in the 1980s, was not fully realized until 2007.
The impetus behind this mandate was the pursuit of professional legitimacy and
the desire to better prepare new nurses for practice in an increasingly complex
healthcare system (Kirkwood 2005; McIntyre et al. 2006). The BETP mandate
effectively collapsed three existing educational pathways into one single route for
becoming a registered nurse (RN) in Canada. Two- and three-year hospital- and
college-based diploma programs were closed or folded into existing four-year
university-based degree programs. Seen by some as a victory for professional
nursing and an affirmation of the value and complexity of nursing knowledge,
the establishment of BETP nonetheless left others wondering whether the move
to universities signified a privileging of theoretical knowledge over practical skills.
Having universities as the de facto site for nursing education exacerbated concerns
that higher education prepares nurses for something other than the role in which
most nurses are actually employed: as caregivers to sick and injured individuals in
hospital settings.
Tensions between Professional and Vocational Identity: The Rise of the BSN
One impetus for discussions of a baccalaureate degree as entry to practice was
a belief that its absence acted as a barrier to the establishment of nursing as a
profession (Kergin 1970). Higher standards of education were thought to increase
the social legitimacy of nursing (Baumgart and Kirkwood 1990; Hermann 2001;
McPherson and Stuart 1994; Saarinen 2008). As separate, service-oriented institu-
tions based on assumptions of the feminine propensity to care and serve, hospital
schools of nursing lacked parity with other professional programs such as engi-
neering, medicine and education. Without educational parity, it was feared, the
profession would never be taken seriously, develop its own body of knowledge,
have control over its own preparation or advance to being an equal partner in the
healthcare system (Kirkwood 2005). Many nursing leaders believed that to realize

its full potential the profession would need to be less focused on “training” and
more on “educating” nurses – that is, to exchange the traditional apprenticeship
model for a curriculum that placed greater emphasis on the humanities and social
sciences (Hermann 2001; Paul and Ross-Kerr 2011).
Integrating liberal arts with traditional (technical) and emerging (theoretical)
nursing knowledge promised to foster critical thinking, situate nursing within a
humanistic perspective, support personal and professional development of the
student, promote social consciousness for citizenship and social reform, promote
the acquisition of general knowledge and prepare students for complex healthcare
environments that were constantly changing (Hagerty and Early 1992; Hermann
2001; Priest 1970).
While Mussallem and the Royal Commission on Health Services (Hall et al. 1965)
proposed a two-tiered system with baccalaureate-prepared leaders and diploma-
prepared bedside nurses, in actuality the realization of BETP threatened to elimi-
nate the second tier. In the absence of diploma graduates traditionally trained
for hospital-based care, it became unclear as to who would be best prepared to
provide bedside care. Baccalaureate-prepared nurses may have been expected to
step into the gap, but baccalaureate nursing programs in the 1990s and beyond
reflected the widely held belief that healthcare was (and is) moving from acute
care into the community (CNA 2008; ICN 2003; WHO 2008). In anticipa-
tion of a new era in healthcare in which greater emphasis would be placed on
health promotion and illness/injury prevention at the population level (Cohen
and Gregory 2009), baccalaureate nursing programs continued to emphasize a
community health perspective that had, in previous years, distinguished baccalau-
reate education from diploma education.
Not all nurses were in favour of BETP (Brooks and Rafferty 2010). To some, the
occupational culture produced by the apprenticeship model of hospital train-
ing schools seemed to prepare students better “for the real world they faced than
the professionalization campaigns of an elite minority of nurses” (Strong-Boag
1991: 238). Nursing unions also largely opposed the baccalaureate policy, most
likely because their focus was on member remuneration, working conditions
and defending job security and upward mobility for diploma-prepared nurses
(Rhéaume 2003). Some nurses and nursing leaders were concerned that bacca-
laureate-prepared graduates would be less competent and lack the level of skill
and knowledge of a hospital-trained, diploma-level nurse (Bonin 1977; Crowe
1991; Kergin 1970). Today there is little evidence that the primary healthcare
ideals so strongly represented in Canadian baccalaureate nursing curricula have
actually come to fruition at the system level. If baccalaureate education was origi-
nally intended to prepare nurses for roles beyond bedside nursing (and within

an as-yet-unrealized primary healthcare model), it should not be surprising that
the question continues regarding whether baccalaureate education adequately
prepares nurses for acute care roles.
Tensions between Theoretical and Practical Knowledge: The Case of Practical
Nurses
Although Mussallem and the Royal Commission on Health Services (Hall et al.
1965) identified two tiers of registered nurse preparation – a baccalaureate level
for leadership and complex care, and a diploma level for bedside care – there
has long been a third class of nurses: practical or vocational nurses (and even
a fourth class, if one considers care aides). Largely relegated to the margins of
nursing history, education and practice, practical nurses have nonetheless been a
relatively inexpensive staple of the Canadian healthcare system since the Second
World War. Intended as a temporary solution to the wartime shortage and as
assistants to registered nurses, the utilization of practical nurses allowed RNs to
focus on increasingly specialized and complex nursing care needs (Ford 1965;
Paul and Ross-Kerr 2011; Saarinen 2008). When RN shortages continued after
the war, so did the market for practical nurses. The shorter training period and
lower wages made the schooling and hiring of practical nurses economically desir-
able (Saarinen 2008) – a trend that continues to this day, with senior licensed/
registered practical nurses (LPNs/RPNs) earning 14–20% less than newly gradu-
ated baccalaureate-prepared registered nurses (BCNU 2013; UNA 2012). Practical
nurses were never intended to replace registered nurses, yet RNs have long
expressed fear that practical nurses might do just that (Ford 1965; Saarinen 2008).
And in the post-BETP world of Canadian nursing, it seems apparent that this is
exactly what is happening: it is LPNs/RPNs who now occupy the second tier of
nursing practice previously held by diploma nurses – albeit with a less standard-
ized (and, some would argue, less rigorous) system for education, licensing
and registration. In this sense, Mussallem’s vision of two tiers of nurses has been
realized, with baccalaureate-prepared nurses and practical nurses occupying
essential positions in the nursing staff mix (CNA 2005).
Nursing Education: Emerging from the Past and into the Future
According to the CNA’s A Nursing Call to Action (National Expert Commission
2012), nursing continues to value community care that focuses on health
promotion and that acts on the determinants of health. The National Expert
Commission continues the as-yet-unrealized transformation of “our out-of-date,
hospital- and illness-focused system into one that looks at the whole patient
through the lens of the social and economic determinants of health, and provides
care to people that reflects how they live in their community” (National Expert
Commission 2012: 30). Nurses, other professionals and the public across Canada
favour an acceleration of the transition from acute care to community care,

better service integration, greater health promotion at the population level and
addressing the root causes of poorer health (National Expert Commission 2012);
however, lack of commitment at all levels of government makes realizing these
aspirations unlikely, at least in the near future.
Despite political support for the baccalaureate degree as entry to practice, histori-
cal concerns about the value of education versus service, professional versus
vocational identity and theoretical versus practical knowledge continue to inform
nursing discourse today. While it is clear that a two-tiered system of education
and practice exists, what remains unclear is whether baccalaureate education is, or
was ever, intended to fill the second tier – the one focused on direct bedside care,
primarily in acute care settings. Until or unless the Canadian healthcare system
shifts more resources to primary healthcare (prevention and health promotion),
the need for bedside nurses will remain a key driver for economic decisions
regarding nursing education and practice. The question remains: How do we best
prepare nurses – baccalaureate and practical – for the realities of a healthcare
system that requires, and deserves, excellence in bedside nursing? The historical
tendency to stratify nursing in Canada into two tiers – with differentiated roles,
status and pay – continues to influence Canadian education and practice today.
We urge nursing leaders to consider what it means to nursing to allow this strati-
fication and the assumptions underlying it to continue unchallenged. While nurs-
ing leaders recognize that baccalaureate-prepared nurses are needed across the
healthcare system, we suggest that until we challenge the uncritical acceptance of a
two-tiered (or more) nursing system – or unless we are willing to critically exam-
ine how “status,” historically embedded in the different tiers, influences decisions
about education and practice – we will not resolve the question of what the role of
baccalaureate nurses should be in healthcare today.
What is needed, then, is a continued effort at all levels of Canadian nursing to be
proactive in the radical transformation of nursing education (Benner et al. 2010),
nursing practice (Browne et al. 2012; Gottlieb et al. 2012; Villeneuve 2006) and
healthcare organization and funding (National Expert Commission 2012). It is
timely, also, for a review of nursing education in Canada, given that a compre-
hensive national review of nursing education has not been completed since
Mussallem’s (1960) report. Nurse leaders are also calling for such a review – one
that will provide curricular direction that will help nursing education adapt to
the changing needs of Canadians and the changing healthcare system (Eggertson
2013; MacMillan 2013; MacMillan and Gurnham 2013). Surely the ideal of a well-
educated professional nurse remains. But without clarity regarding what we are
preparing nurses for, or clarity regarding how a historically informed resistance to
baccalaureate-prepared nurses at the bedside influences messages about the rela-
tive importance of bedside excellence, the two-tier approach to nursing education
and practice that assigns less status to bedside nursing will continue unchallenged.

Correspondence may be directed to: Em M. Pijl-Zieber at the Faculty of Health Sciences,
University of Lethbridge; Telephone: 403-332-5232. E-mail: em.pijlzieber@uleth.ca.
References
Baumgart, A.J. and R. Kirkwood. 1990.“Social Reform versus Education Reform: University
Education in Canada, 1919–1960.” Journal of Advanced Nursing 15: 510–16.
Benner, P., M. Sutphen, V. Leonard and L. Day. 2010. Educating Nurses: A Call for Radical
Transformation. San Francisco: Jossey-Bass.
Bonin, M.A. 1977. Trends in Integrated Basic Degree Nursing Programs in Canada, 1942–1972.
Doctoral dissertation, University of Ottawa.
British Columbia Nurses’ Union (BCNU). 2013. Wage Rate Schedule. Retrieved April 28, 2014.
https://www.bcnu.org/ContractAdministration/pdf/NBA%20Wage%20Grid%202011_2013.pdf.
Brooks, J. and A.M. Rafferty. 2010.“Degrees of Ambivalence: Attitudes towards Pre-Registration
University Education for Nurses in Britain, 1930–1960.” Nurse Education Today 30(6): 579–83. doi:
10.1016/j.nedt.2009.12.004.
Browne, G., S. Birch and L. Thabane. 2012.“Better Care: An Analysis of Nursing and Healthcare
System Outcomes.” Canadian Health Services Research Foundation’s Series of Reports to Inform the
CNA National Expert Commission – Part II. Ottawa: Canadian Nurses Association.
Canadian Nurses Association (CNA). 2005 (January).“Nursing Staff Mix: A Key Link to Patient
Safety.” Nursing Now: Issues and Trends in Canadian Nursing 19. Retrieved April 28, 2014. https://
www.cna-aiic.ca/~/media/cna/page%20content/pdf%20en/2013/07/26/10/40/nn_nursing_staff_
mix_05_e.pdf.
Canadian Nurses Association (CNA). 2008. CNA’s Preferred Future: Health for All. Ottawa:
Author. Retrieved April 28, 2014. http://www.cna-aiic.ca/~/media/cna/page%20content/pdf%20
en/2013/07/26/11/04/preferred_future_webcast_e.pdf.
Cohen, B.E. and D. Gregory. 2009.“Community Health Clinical Education in Canada: Part 1 – ‘State
of the Art’.” International Journal of Nursing Education Scholarship 6(1): 1–17. doi: 10.2202/1548-
923X.1637.
Crowe, S.J. 1991. Who Cares? The Crisis in Canadian Nursing. Toronto: McClelland Stewart.
Eggertson, L. 2013.“The Gap between Clinical Practice and Education.” Canadian Nurse 109(7):
22–26.
Ford, A. 1965.“Dilemma of the Nursing Assistant.” Canadian Nurse 61(4): 297–99.
Gottlieb, L.N., B. Gottlieb and J. Shamian. 2012.“Principles of Strengths-Based Nursing Leadership
for Strengths-Based Nursing Care: A New Paradigm for Nursing and Healthcare for the 21st
Century.” Canadian Journal of Nursing Leadership 25(2): 38–50.
Hagerty, B.M.K. and S.L. Early. 1992.“The Influence of Liberal Education on Professional Nursing
Practice: A Proposed Model.” Advances in Nursing Science 14(3): 29–38.
Hall, E.M., A. Girard, D.M. Baltzan, O.J. Firestone, C.L. Strachan, A.F. van Wart et al. 1965. Royal
Commission on Health Services. Ottawa: Government of Canada.
Hermann, M.L.S. 2001. The Current Nature of the Integration of the Humanities within Baccalaureate
Nursing Education. Doctoral dissertation, Widener University, Chester, PA.
International Council of Nurses (ICN). 2003. ICN Framework of Competencies for the Generalist
Nurse: Report of the Development Process and Consultation. Geneva: International Council of Nurses.
Kergin, D.J. 1970.“Nursing as a Profession.” In M.Q. Innis, ed., Nursing Education in a Changing
Society (pp. 46–63). Toronto: University of Ontario Press.
Kirkwood, L. 2005.“Enough But Not Too Much: Nursing Education in English Language Canada
(1874–2000).” In C. Bates, D. Dodd and N. Rousseau, eds., On All Frontiers: Four Centuries of
Canadian Nursing (pp. 183–96). Ottawa: University of Ottawa Press.

MacMillan, K. 2013. Proceedings of a Think Tank on the Future of Undergraduate Nursing Education in
Canada. Halifax: Dalhousie University School of Nursing.
MacMillan, K. and M.E. Gurnham. 2013.“Leaders Hold an Invitational Think Tank on
Undergraduate Nursing Education.” Canadian Journal of Nursing Leadership 26(2): 25–28.
McIntyre, M., E. Thomlinson and C. McDonald. 2006. Realities of Canadian Nursing: Professional,
Practice, and Power Issues (2nd ed.). Philadelphia: Lippincott Williams Wilkins.
McPherson, K. and M. Stuart. 1994.“Writing Nursing History in Canada: Issues and Approaches.”
Canadian Bulletin of Medical History 11(1): 3–22.
Mussallem, H.K. 1960. Spotlight on Nursing Education: The Report of the Pilot Project for the
Evaluation of Schools of Nursing in Canada. Ottawa: Canadian Nurses Association.
Mussallem, H.K. 1964. A Path to Quality: A Plan for the Development of Nursing Education Programs
within the General Educational System of Canada. Ottawa: Canadian Nurses Association.
National Expert Commission. 2012. The Health of Our Nation, the Future of Our Health System.
A Nursing Call to Action. Ottawa: Canadian Nurses Association.
Paul, P. and J.C. Ross-Kerr. 2011.“The Origins and Development of Nursing Education in Canada.”
In J.C. Ross-Kerr and M.J. Wood, Canadian Nursing: Issues and Perspectives (5th ed.). Toronto:
Mosby Canada.
Priest, R.R. 1970.“The Humanities in the Nursing Curriculum.” In M.Q. Innis, ed., Nursing
Education in a Changing Society (pp. 184–89). Toronto: University of Toronto Press.
Rhéaume, A. 2003.“Establishing Consensus about the Baccalaureate Entry-to-Practice Policy.”
Journal of Nursing Education 42(12): 546–52.
Romyn, A. 1990.“The Future of Nursing Education within British Columbia’s Community
Colleges.” Master’s thesis, University of British Columbia, Vancouver, BC.
Saarinen, J.M. 2008.“Dominant Discourses and Ideologies That Have Shaped the Education of
Registered Nurses and Licensed Practical Nurses in Canada.” Master’s thesis, University of Victoria,
BC.
Strong-Boag, V. 1991.“Making a Difference: The History of Canada’s Nurses.” Canadian Bulletin of
Medical History 8: 231–48.
United Nurses of Alberta (UNA). 2012.“Appendix of Nursing Salaries in Alberta 1948–2013.”
Retrieved April 28, 2014. http://www.una.ab.ca/files/130/2012-07-04_Appendix_of_Nursing_
Salaraies_in_Alberta_1948-2013.pdf.
Villeneuve, M.M. and J. MacDonald. 2006.“Toward 2020: Visions for Nursing (Special Report).”
Canadian Nurse 102(5): 22–23.
Weir, G.M. 1932. Survey of Nursing Education in Canada. Toronto: University of Toronto Press.
World Health Organization (WHO). 2008. Primary Health Care: Now More Than Ever. Geneva:
Author.

35
Critical reflection on the introduction of baccalaureate education as the entry-to-
practice requirement in Canada is timely. Major changes in the healthcare needs
of the population are emerging and are likely to grow exponentially in the next
three decades. Efforts to chart future directions for nursing education in this
changing context must take into account long-standing issues from the past.
The authors (Pijl-Zieber et al. 2014) identify historical tensions between the
immediate needs of the health services sector and the population’s needs for an
appropriately educated nursing workforce. Differing perspectives about what
constitutes an appropriate education for nurses have been rooted in tensions
between both professional and vocational nursing identities, and theoretical
versus practical knowledge.
Hospital Training Schools
The authors note that lay education for nurses in Canada began in 1874, when
Dr. Theophilus Mack established a hospital training school in St. Catharines,
Ontario with the assistance of two nurses who had trained under Florence
Nightingale (Kirkwood 2005). Convinced that respectable young women educated
to be nurses were needed to improve hospital outcomes, Dr. Mack wrote:“all
the most brilliant achievements of modern surgery are dependent to a great
extent upon careful and intelligent nursing” (cited in Gibbon 1947: 145). He also
Future Directions for Nursing Education
Cynthia Baker, RN, PhD
Executive Director,
Canadian Association of Schools of Nursing
Ottawa, ON
COMMENTARY

believed that trained nurses would alter the public’s prejudice against hospitals.
These views reflected an international movement involving “the ascent of medical
control” and “the evolution of hospitals from charitable and custodial institu-
tions to socially respectable and therapeutic ones” (McPherson 1996: 6). This shift
required an educated nursing workforce.
Dr. Mack stressed the educational component of the training school, arguing that
“every possible opportunity is seized to impart instruction of a practical nature
in the art of nursing, while teaching will be given in chemistry, sanitary science,
popular physiology and anatomy, hygiene and all such branches of the healing art”
(cited in Gibbon 1947: 145). The training was based on apprenticeship, however,
and nursing students quickly became the workforce of a rapidly burgeoning
system of hospitals and hospital-based healthcare.
Economic benefits quickly became the major driving force of the hospital training
school. Except for a very small number of supervisors and instructors, students
provided all nursing services in the hospital. Nevertheless, the initial desire to
increase the social acceptability of hospital care by training nursing students
continued. Entrance requirements were used to define nursing as a respectable
occupation for young, single Caucasian women. Applicants were required to
be unmarried or widowed females between 18 and 35, with a grade 9 educa-
tion (which soon increased to grade 11 or 12), who spoke English or French
proficiently. Until the 1940s, no African-Canadian or First Nation women were
admissible (McPherson 2005). The schools kept their young, female workforce of
nursing students under tight control and in a highly subservient position to the
hospital physicians.
Professional Education for Nurses
Concerns about the quality of hospital training soon emerged, and by the begin-
ning of the 20th century nurses had begun to look to universities to educate a
cadre of nursing leaders. University education was seen as a preparation for a
small group of nurses to become teachers, supervisors and public health nurses
rather than the educational path for all nurses (McPherson 1996).
In 1905, the Graduate Nurses’ Association of Ontario formally requested the
University of Toronto to offer a course of education for nurses (Paul and Ross-
Kerr 2011). Although this request was unsuccessful, a push for university educa-
tion continued throughout the next two decades. In Vancouver, the superinten-
dent of the Vancouver General Hospital and the provincial medical officer of
health vigorously promoted university education for nurses in order to reform
hospital and community healthcare. This impetus led to the introduction of
a five-year baccalaureate nursing degree program at the University of British
Columbia in 1919 under the direction of Ethel Johns (Davidson Dick and Cragg

37Commentary: Future Directions for Nursing Education
2003). During the decade that followed, postgraduate public health nursing
programs were established at universities across Canada (Kirkwood and Bouchard
1992), and in 1924, the University of Western Ontario established a degree
program, followed by the University of Alberta in 1925.
Nursing Education Reform
There was an expansion of hospitals following the Second World War. Nursing
positions increased significantly during this period as a result of new medical
technologies that were “contingent on the availability of reliable skilled nurses”
(Toman 200: 101). The Royal Commission of Health Services, led by Justice
Emmett Hall, resulting in the 1966 Medical Care Act, included recommendations
for nursing education. The Hall report called for a separation of nursing educa-
tion from hospital services (Hall et al. 1965). Two categories of programs were
recommended. Approximately 25% of nursing students were to be educated in
a four- or five-year professional university program for public health, adminis-
trative, instructor and supervisory positions. The report recommended that 10
additional university schools of nursing be established to support the education of
professional nurses. Seventy-five per cent were to be educated as bedside nurses in
a two-year, technical diploma program (Hall et al. 1965).
The Hall report successfully launched the demise of the hospital training schools
as well as 10 additional baccalaureate nursing programs. Nursing education
in Quebec, Ontario and Saskatchewan moved out of hospitals into colleges of
applied arts and technology, and non-hospital schools of nursing were opened in
other parts of Canada. Some hospital schools, however, remained in existence in
Alberta, British Columbia, Manitoba and Nova Scotia into the 1990s.1
There was considerable criticism from employers following the closing of hospital-
based training. They argued that students were inadequately prepared for the “real
world” of practice (Davidson Dick and Cragg 2003).
Baccalaureate Degree as Entry to Practice
While a baccalaureate degree was increasingly required for supervisory positions
and in public health, both the “professionally educated” university graduates
and the “technical” diploma school graduates tended to enter practice in bedside
nursing roles in the acute care sector. Moreover, the complexity of bedside nurs-
ing grew significantly during the 1970s as patient acuity increased and intensive
care units proliferated. The need to scale up the education for all registered nurses
soon became a major topic of debate.
In 1982, the board of the Canadian Nurses Association adopted a resolution that
university preparation be the entry-to-practice requirement by the year 2000
(Paul and Ross-Kerr 2011). By the end of the decade, all provincial associations

except Quebec’s had endorsed this position. Provincial governments concerned at
possible cost increases, and colleges who did not want to lose what was often their
largest program, rather than physicians and employers, were the major stakehold-
ers involved in this issue.
Despite the debates, colleges and universities began to work together to establish
collaborative partnerships to offer the baccalaureate degree in joint programs, and
often well before entry-to-practice implementation dates were established in their
jurisdiction. Between 2000 and 2010, the baccalaureate degree became the entry-
to-practice requirement throughout Canada, with the exception of Quebec. This
requirement was achieved to a large extent through collaborative partnerships
established between colleges and universities.
Current Trends and Issues
A global shortage of nurses emerged as collaborative programs were being estab-
lished. Enrolments increased steadily, and by 2010 had more than doubled in 10
years (CASN and CNA 2013).
Programs for practical nurses also grew to address the shortage, and were length-
ened to accommodate an increased scope of practice. This situation reintroduced
the notion of professional versus technical nursing. Nurse practitioner programs
also grew during the same period, bringing an advanced nursing level to the long-
standing issue about nursing identities. In addition, inter-professional and intra-
professional education were being introduced across health professions to prepare
graduates for collaborative patient-focused teams.
Shaping the Future
The global nursing shortage has subsided, but nursing education in Canada faces
a rapidly changing context that will affect the nature of nursing education. With
the first baby boomers now 67 years old, people living with multiple, complex
chronic conditions are increasing, there has been a 100% increase in home care,
the prevalence of dementia is increasing, the need for palliative and end-of-life
care is increasing, and projections indicate that these trends will magnify as the
population continues to age (Canadian Healthcare Association 2009).
Despite these trends, the acute care hospital remains a major employer of nurses.
In 2011, 62% of Canadian registered nurses worked in acute care hospitals
(CIHI 2013). Although the length of stays has decreased (Canadian Healthcare
Association 2009), nurse–patient ratios have also dropped as patient acuity
continues to climb.
Multiple challenges must be addressed in shaping the future of nursing education
for registered nurses. These include the integration of theoretical and practical

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