ARISTOTLE wrote that each citizen has a duty to honor the obligations of the community.1 Some believe nursing's obligation is to honor the health care system or the profession. I propose that nursing's obligation is neither to the nurse nor to the system, but rather to the patient. If the patient is our obligation, then nursing's highest duty is the provision of quality patient care. No other obligations matter. It is the quality of nursing care that makes the difference in mortality and morbidity of patients. Nursing education plays a critical role in assuring this quality. If nursing education is not ultimately focused on preparing nurses to provide the highest level of care, regardless of what is best for students, schools, and employers, then I believe we have failed in our ultimate duty, which is to patients.
WHY A MORE EXPANSIVE EDUCATION IS IMPORTANT TO CARE AND CLINICAL DECISIONS
To build a strong, effective, and innovative clinical profession, we must either make the baccalaureate, with its liberal arts base, the minimum acceptable first degree or require a postbaccalaureate entry. There are many arguments that have been put forth against the baccalaureate entry including financial considerations, time involved, and most importantly, work experience as a substitute for education.2 However, work experience and education are not synonymous and to suggest work as a substitute is to evoke an anachronistic apprenticeship model. Ultimately, it is an excellent and expansive baseline education followed by quality work experience that provides the essential foundation for nursing care.
I propose that the first 2 years of a baccalaureate are as important to the provision of excellent patient care as basic nursing courses themselves. The recent Carnegie report on nursing education emphasizes the important role an expanded education rich in the humanities and sciences play in the increasing complex and technological provision of health care.3 Indeed, as health care itself become increasingly complex and technology-based, nurses will need even more education if they are to be equipped to meet the challenge of providing quality care in a multifaceted health care environment. Without the liberal arts background of a baccalaureate, the quality of the nurses' vision will be narrowed as will the care they are able to provide.
Ernest Boyer notes, "But to be truly educated means going beyond the isolated facts, it means putting learning in larger context, and above all it means, to return to my favorite word, it means discovering the connectedness of things."4 I argue that to provide quality care, nurses must be able to see patients in a larger context. The liberal arts coursework of a baccalaureate provides for this larger context through exposure to essential and varied decision-making templates as well as cross-disciplinary thinking (See Box 1). It is the broader educational base, including music, literature, economics, and so forth that provides the richer, more complete, and artful care and clinical decision making than do nursing courses alone.
Educational exposure to the humanities facilitates an understanding of the world beyond the narrow confines of self-experience. To illustrate the importance of humanities to nursing care, consider that most nurses will never have tuberculosis (TB), nor care for someone with TB as a nursing student. Yet many nurses will have contact with TB patients during the course of their careers. Imagine the richer care that can be provided by a nurse who has taken a music appreciation course that included La Boheme or La Traviata (both of which include lead characters with TB) or a literature course that discusses Dostoevsky's Crime and Punishment, or Thomas Mann's The Magic Mountain with their portrayals of TB and sanatoriums. These classics expand understanding of TB beyond its pathology and medical treatment and allow the nurse to touch the soul of suffering through a broader sense of the human condition (see Box 2; for additional examples I offer of literature and coursework that augments nursing knowledge).
The broader the base of knowledge, the better the ability to solve problems and further to construct new knowledge from seemingly unrelated information.5 This broader base of knowledge is important not only for a deeper understanding but because new knowledge is first understood in terms of the heuristic base of previous learning.6,7 Course work in history provides an historical understanding of decisions; economics, an economic context; sociology, a sociological perspective, and so forth. Each of these different worldviews, or Weltanschauung, provides a framework for generating, sustaining, applying, and evaluating knowledge. The humanities are often viewed as nice but not essential to nursing care,8 but nursing knowledge provides only one view of the world. Students whose baccalaureate nursing education builds upon humanities as well as the sciences will understand nursing within the larger context of the human condition. Understanding may be conscribed in associate degree or diploma students whose nursing courses build mostly upon a scientific base.
Tversky and Kahneman's prospect theory (for which Kahneman won the Nobel Prize in economics) proposes that people make different decisions depending upon expected risks and how the decision is framed.9 Framing is the lens through which a problem is viewed. For instance, if the problem is framed as one of economics, it may be solved differently than would a social problem. The more frames available to a decision, the more varied the decision possibilities, and the better the chances that the decision will be the right one. A nursing education that is predominately based on the scientific method and its derivative, the nursing method, may restrict clinical decision making by reducing the knowledge frames available to the decision and by what Feyerabend might call an unrealistic belief in the power of rational decision making.10 Tversky and Kahneman were able to show that good economic decisions regularly violate the principles of ideal rational thinking11 and instead show evidence of bounded, or limited rationality.12
When nursing coursework builds upon the humanities as well as the sciences, the heuristic base for clinical care and problem solving is expanded. The time constraints of an associate degree mean that these programs focus mainly on science and nursing courses. When nursing coursework builds primarily upon the sciences, it may result in an over reliance of decision-making models based on the scientific method. Thus, I propose that clinical problem solving based on the scientific method and the nursing process is good, but not sufficient to facilitate best care practices.
Concentrated curriculums may have the unintended consequence of producing graduates who have not been exposed to the many alternate knowledge bases that contribute to care and creative problem solving. If the knowledge available to frame clinical decision making is limited and nurses only rely on one form of decision making, we breach our duty to the patient because our care will be limited as well.
ETHICAL CONSIDERATIONS
Modern ethical discourse in health care is commonly divided into 2 approaches: duty and utility. Duty ethics is attributed to Immanuel Kant, who wrote that doing what is right comes from adherence to rules or duties regardless of the consequences.13 According to Kant, there are perfect and imperfect duties. Kant referred to the perfect duty as a moral imperative.13 Utilitarian ethics, conceptualized by philosophers Jeremy Bentham14 and John Stuart Mill,15 emphasize the costs and benefits of ethical decision. It is characterized by achievement of the greatest good for the greatest number.
What is the perfect duty of nursing?
Nursing's primary duty is to provide care to those who cannot provide it for themselves. The duty to provide nursing care is absolute. However, all patients, no matter their circumstances, deserve more than just care, they deserve excellent nursing care. I would argue that the perfect duty of nursing is to provide excellent care. Such care is not static nor is it uninformed.
The educational system is a critical component in the provision of quality nursing care. The very best care is based on current evidence and is individualized to the patient. Currency and individualization are in turn built upon an essential educational base that provides the knowledge and skill sets necessary to develop and utilize evidence-based nursing as well as to look beyond the ordinary and expected in planning care.
Unlike our health care colleagues, the nursing profession seems unable to reach consensus about the role of education in the provision of care. Perhaps this is because nursing has not analyzed the obligations of nursing education a priori, but rather responded a posteriori to educational and practice dilemmas. Kant warned against a posteriori arguments. They taint the view of moral duty through focus on expediency and relativity.13 One result of the a posteriori response may be that we have differences in basic education and remain unclear as to what the differences mean for patient care. This lack of clarity confuses all the constituencies involved and weakens the future of nursing education and the profession.
I contend that the nurse's duty to others, such as hospitals, colleges, and employers, is imperfect. Nurses owe employers currency of nursing knowledge, the ability to solve critically clinical problems, and the provision of excellent patient care. Nursing educators owe students an excellent education that includes both essential knowledge and the tools to be lifetime learners. However, the ultimate duty, the moral imperative of nursing, is to provide quality patient care. Education is the vehicle to that end. No duty to the employer or student (imperfect duty) overrides that of nursing's duty to provide quality care to the patient (perfect duty).
What is the greatest number and what is the greatest good?
Much of the discussion surrounding the essential nature of basic nursing education relies not on duty but on the utilitarian argument of providing the greatest good for the greatest number. This argument is made without consideration of greatest good for whom and indeed, what constitutes goodness. I argue that the greatest good for nursing derives from our duty (to provide quality care) and thus, should be to provide quality care for the greatest number of patients.
Goodness in education is predicated on the production of nurses who are best able to provide the highest quality care to the greatest number of patients. This is very different from the more common argument where it seems that the preparation of the greatest number of nurses for the greatest number of employers is the marker for goodness.16 The number of nurses is often presented as the only viable solution for provision of quality care 17,18; however, numbers do not guarantee quality.19
Quality "goodness" is both difficult to ascertain and measure. Currently, there are several commonplace markers that indicate goodness of nursing education and nursing care. For example, educational programs are accredited by professional organizations and reviewed by the appropriate state organizations. The same is true of accredited hospitals. All accredited programs can assure the public that the nursing coursework or care meets minimum acceptable standards and thus, provides a measure of goodness. As awareness of quality grows, efforts such as the American Nurses Credentialing Center designation of Magnet Status have allowed hospitals to showcase nursing excellence beyond that of hospital accreditation.20
Another major outcome marker of goodness in educational programs, and for the graduating student, is first time pass rate on the national licensure exam (NCLEX). NCLEX pass rates are the most common argument used to validate the parity of the educational programs because associate degree, diploma, and baccalaureate graduates perform on par with one another on the examination.2,21,22 The parity of pass rates is not surprising given that the exam is focused only upon traditional and fundamental nursing content. All types of programs are able to achieve adequate pass rates on the NCLEX as all programs teach the same basic nursing content tested in the exam.
Licensure only assures that a nurse has a minimum acceptable level of nursing content knowledge at the time of examination. The State Boards of Nursing maintain licensure standards and monitor breaches of professional behavior but do not measure quality. Thus, state imprimatur and NCLEX passage are necessary, but certainly not sufficient, markers of goodness.
Commonly used proxy variables for nursing care goodness are labeled as quality indicators. Acute care nursing quality indicators include several measures that are controlled by the nurse including patient falls, pressure ulcers, restraints, and nosocomial infections.23 Although not under the control of the individual nurse, staffing ratios are often cited as another major quality indicator.24 Aiken and others have reported evidence that hospitals with fewer registered nurses per patient have higher rates of morbidity including the aforementioned life threatening pneumonias, shock, and decubitus ulcers.25,26 There is also some beginning evidence that baccalaureate degrees may also play a role in reduction of mortality rates.27 Because numbers are compelling and perhaps because they are easy to understand, numbers of nurses and staffing ratios have subsumed much of the clinical goodness discussions such that there is the impression that if we only had the right number of nurses, quality would take care of itself.28
The main focus of the utilitarian argument (greatest good for greatest number) appears to be staffing for the health care system, focusing on the provision of the greatest number of nurses for the greatest number of employers, rather than the provision of the greatest good (patient care) for the greatest number (patients). The health care system, financial markets, and politics--not nursing-have driven most of the attempted solutions to the quantity problem.29 The solutions include allowing international nurses favorable visa status, recruiting by large hospital systems of foreign nurses, proliferation of more associate degree programs, shortened onsite educational programs for licensed practical nurses, and other staff to become registered nurses, and distance learning.30-34 Some of these nonnurse driven solutions have had a profound influence on the profession of nursing, nursing education, and nursing care.35-37
There is an inherent problem in the view that all nurses are substitutable and only the raw numbers of nurses are important to quality. The focus on numbers assumes that quality falls into a very narrow band that basically divides nursing care into "good" and "none", as a proxy for "not good". It is commonly held that all nursing care is equal in quality, although we know that quality is not a dichotomous variable. The Quality and Safety Education for Nurses project has noted that although there is tremendous will to provide good care, nursing has yet to define what that means.38 This view is not isolated to nursing. Until recently, physicians and hospitals have all been viewed as more or less equal in quality. Recent innovations such as Magnet Status hospital designations and the physician and hospital report cards are beginning to make inroads into the quality differentiation conundrum (See for example: http://www.leapfroggroup.org, http://www.checkbook.org, http://www.healthgrades.com, and http//www.medicare.gov/hospital/home.asp). While these steps are important, none of these efforts focus on education. I argue that quality care is possible only if there is also the best quality education.
THE ESSENTIAL ETHICAL IMPEATIVE OF NURSING EDUCATION
Nursing education must first be good in and of itself, and not good by virtue of its relationship to other entities such as schools and hospitals. The number of nurses is not as important to the provision of care as the quality of nurses produced. Pragmatically, nursing education should prepare the workforce. Idealistically, nursing education should prepare an educated constituency who can improve patient care. Realistically, the profession of nursing needs it all, an adequate number of nurses prepared at the baccalaureate level, who can improve patient care.
Nursing's ethical duty derives from the commitment to provide the best care for the greatest number of patients (the greatest good for the greatest number) and therefore, subsumes the argument for quantity over quality. As with all health care professions, clinical excellence is dependent; first upon a solid educational foundation and second upon experience. The essential nursing education must include a broad liberal arts base, rich in the humanities followed by the critical nursing knowledge. Without humanities, as well as science and nursing courses, we compromise the care provided to the patients of the future because we have reduced the "frames" available to care and clinical decisions.
Clinical judgments should be informed by an expansive educational background, otherwise we risk parochial, isolationist, regressive thinking in an increasingly complex global community. An abbreviated education negates the value of an educational base rich in decision-enhancing benefits of humanities and other coursework. Our failure to acknowledge the importance of a more expansive education to patient care is morally indefensible for it benefits neither patient nor the profession.
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