VIEWS OF LEADING NURSE EDUCATORS REGARDING THE COMPREHENSIVE BASIC NURSING PROGRAMME

This article describes a Delphi survey amongst nurse educators in South Africa. The aim was to describe their perceptions regarding the reasons for the comprehensive basic nursing programme (CBNP), its aims and expected outcomes. There was general agreement that the programme was necessary, and that it was designed mainly to produce a nurse who could function in a comprehensive health service. Integration of information and economic arguments were also mentioned. Making available a nurse who can deliver a comprehensive seivice to all people, was also seen as the main aim of the programme. Independent learning, competency in a whole range of skills, the ability to function in a multidisciplinary team and high level cognitive skills were mentioned as additional aims.


INTRODUCTION
In sp ite o f the v a rio u s a tte m p ts at reorganisation and change, problems facing nursing education in South A frica have remained more or less the same over a number of years.Uys (1991) presented a chronological account of the problems in nursing education from 1966 to 1987.Perusal of such problems exemplied by lack of correlation between theory and practice, multiple subject teaching for tutors, unavailability o f tutors in the clinical settings, and nursing students used as part o f the workforce continue to haunt nursing education to the present day.
Uys observed that although some of these problems still exist, the nursing profession in South Africa h«s stopped complaining about them.She attributed the failure of the profession to attend to outdated problems to nurse educators' tendency to criticise what is new, "probably because it demands so much more effort, initiative, and perseverance from the tutor to solve problems in a new way and to make new systems work" (Uys 1991,118).
Efforts at reorganisation of nursing education in the country have been many and varied, but few, if any, have been subjected to any analysis.Tins study investigates the reasons, a im s, and e x p e c te d o u tc o m es o f the Comprehensive Basic Nursing Programme (CBNP).

BACKGROUND
The passing of the South African Nursing Council (S ANC) regulations (R. 245 of 1985) sounded a death knell to the existing three and a hall year basic nursing programmes in the country.Regulation 245 made it compulsory fo r all in s titu tio n s in v o lv e d in b asic professional nurse preparation to reorganise their basic nursing programmes so as to produce nurses qualified in m idwifery.general-, psychiatric-and community health nursing within a 4-year programme.
For nearly 100 years, the preparation of professional nurses capable of functioning in a comprehensive health care system had been a long and repetitive ordeal.The South African nurse had to spend 6 to 7 years in nursing school in order to obtain these four clinical nursing qualifications.However, it was as early as 1945 when the SANC called for an end to the fragmented approach to professional nurse preparation (Searle, 1983;W oodward, 1991).Sim ilar views were posited by Williamson after an extensive study of the American and South African systems of nursing education.Williamson recommended that "more integrated courses resulting in m u ltip le reg istra tio n be im p lem en ted " (Williamson 1977, 148).The duration of the fragmented programmes was not the only reason for this long overdue transformation in basic nursing education.
The CBNP was intended to be a solution to other problems facing nursing education at the time.Several authorities on nursing education in the country (Loudon, 1984;Nolte, 1985;Searle, 1983;Van Huyssteen, 1989) reiterated the S A N C 's concern about in ad eq u ate preparation of the country ' s nursing force with regard to the provision of comprehensive health care.It is important to note that thi; legislation that transformed tJjfi-heaMT"care d eliv ery system from a p red o m in an tly curative system, to a Comprehensive health system was passed in 1977.In 1983, Searle (1983,5) pointed out that, "statements by the v a rio u s M in iste rs o f H e a lth th a t the Comprehensive Health System is built around the concept that nurses will be the main providers of health care" was one of the reasons for the establishment of the CBNP.According to Loudon (1984) the graduates of the new programme would have varied, comprehensive knowledge, enabling them to function in any health care setting.However, as a consequence of the fragmented approach to nurse preparation, of the total population of registered nurses available in South Africa in 1979,93% were general nurses and 73% were midwives.The two areas of clinical nursing which had been neglected were psychiatricand community health nursing.At the time, only 4.7% and 8.7% of all registered nurses held a registration in community health and Curationis, V ol. 18, No. 1, March 1995 psychiatric nursing respectively.By 1988, these figures had risen respectively to 10.52% and 10.7% (Van Huyssteen, 1989).
Nevertheless, reason for concern as to whether or not the areas highlighted by Van Huyssteen (1989) as reasons for establishing the CBNP were receiving the adequate attention they deserve in nursing colleges was voiced by Alberts (1985).Alberts reported that of the nursing colleges which participated in her study, four responded to the section on her questionnaire that dealt with the new programme.Two of these colleges had already implemented the four-year programme.Alberts reported that there was documented evidence of planned over-teaching in at least three of the four clinical nursing subdisciplines, with general nursing science dominating the curriculum.For instance, while there was virtually no planned over-teaching for psychiatric nursing, the nursing colleges planned to increase the number of hours from 160hrs (as required by the SANC) to 389hrs (143%) for general nursing.
Feelings of discontent with the CBNP have been voiced both formally (at symposia and meetings of university heads of departments) and informally.Personal conversations with some members of the profession and some students have led the researcher to believe that the programme does not enjoy the same enthusiastic support it did at its inception.
It was exactly 5 years after the legislated establishment of the programme that Woodward (1991,3), a member of the SANC, lamented that "the reality of the demands created by the health needs of our society ... together with the complexities of the expectations regarding nurses and nursing, does place a tremendous strain on the continued relevance and credibility of our nursing education programmes".She pointed out that the evaluation strategies used by tutors are nothing but a "painful analysis of a technical skill in order to list its elements so that each can be accorded a mark on a sliding scale" (Woodward 1991,3)

PURPOSE OF THE STUDY
This study was carried out as an initial phase of a major project assessing the change process in nursing education.The aim of this phase of the project was to identify reasons, aims, and expected outcomes of the CBNP as perceived by those nurses directly involved in education.It was hoped that information gained through the Delphi method would pinpoint components of this programme about which leading nurse educators agreed.The components of the CBNP on which consensus was reached would therefore form a basis for the assessment phase of the change.

OBJECTIVES OF THE STUDY
The objectives of this study were to identify (a) reasons, aims, and expected outcomes of the CBNP, (b) teaching/learning activities which would hinder or facilitate attainment of expected outcomes, and (c) aspects of a curriculum that would facilitate or hinder attainment of the expected outcomes.

METHODOLOGY
This study is the first phase of a two-phase change assessment project.This phase of the study used a Delphi approach to identify the above mentioned objectives.

SAMPLE AND SAMPLING PROCEDURE
The targeted population included all the principals of nursing colleges, heads of nursing departments at universities offering the basic nursing programme (N = 44) and members of the South African Nursing Council (N = 10) who were in office in 1983.The decision to include the above mentioned groups of people was based on the belief that they play an important role in shaping basic nursing education in South Africa.Whereas the SANC members shape nursing education directly through regulations, principals of nursing colleges and heads of university nursing departments shape it by controlling the implementation process.For this study, this latter group was seen as leaders in nursing education.

DATA COLLECTION
The 54 potential participants were contacted by mail in which the first round questionnaire and a covering letter explaining the nature of study, and requesting consent for participation, was included.
Of the 44 questionnaires mailed to principals of nursing colleges and heads of university nursing departments, only 20 (45.5%) were returned.
Fifteen of the returned questionnaires were usable.Returns from the ex members of the SANC were two, of which only one was usable.Although these returns are small, they were considered sufficient to yield the necessary information because (a) the Delphi approach requires commitment to participate in research, and (b) a population rather than a sample of the defined nurse leaders (all principals of nursing colleges and all heads of university nursing departments) was used.
For the second round 16 questionnaires were mailed to those panel members who had There would be a better match between the skills of the nurse practitioner and the needs of health services 7 2 4 0 There would be improved quality of nursing services (more patient and less procedure oriented) 9 3 0 0

Graduates of this programme would be able to:
Meet needs of people in health and sickness in all age groups within a comprehensive health service 12 1 0 0 Use independent judgement in nursing practice 10 the second round of the Delphi were rated as either very important or important by all members of the panel.A further five expected outcomes received the strong support of 10-12 respondents.Four members of the panel indicated that it would be nice if the expectation that there would be a better match between the skills of nurses and service needs was achieved.The ratings of the 10 expected outcomes of the CBNP appear on Table 2.

THE FOUR REGISTRATIONS AS INDICATIVE OF ATTAINMENT OF THE OBJECTIVE OF PRODUCING NURSES CAPABLE OF RENDERING COMPREHENSIVE HEALTH CARE
Six out of 13 panel members who participated in the third round of the Delphi maintained that the four registrations awarded by the SANC at the end of the students' four-year programme were sufficient proof that the objective of producing nurses capable of rendering comprehensive health care was attained.Four felt that this was not the case, whereas the remaining three were vague about this issue.
Those who responded affirmatively to this question asserted that because the curricula offered at the nursing colleges are approved by the SANC, and also the fact that the council carries out periodic inspection of nursing colleges, the four registrations were sufficient proof that this objective was attained.However, some of the respondents did not agree with this view.For instance, amongst those who were tentative about the issue one respondent stated:

DIFFERENCES BETWEEN DEPLOMATES OF THE CBNP AND THOSE OF TRADITIONAL NURSING PROGRAMMES
All of the respondents believed that the graduates of the CBNP would act differently from the graduates of the old diploma programmes.According to six of the 13 participants these nurses would be able to write more comprehensive nursing care plans, and make life easy for the nursing service manager in that they could be placed in any service setting upon graduation .Also it was indicated that the new graduates would be better able to integrate knowledge in rendering total patient care.
On a negative note, some of the respondents (4) believed that these nurses lack experience and therefore suffer from feelings of inadequacy, whereas graduates of old programmes were believed to be more competent upon graduation.The ambivalence about exactly what graduates of the CBNP should be doing differently became more succinct in a statement by one of the respondent: In short I think they lack experience, therefore may feel inadequate.I also feel that they acquire only basic knowledge and need post-basic train ing....I do feel these students should be very carefully selected.
However, one of those who spoke positively stated that: In actual fact in assessing diplomates from the four year programme after completion, they are more assertive, critical and logical reasoners ... some of them are now moving into leader positions.

MEANS FOR ASSESSING THE ATTAINMENT OF THE PROGRAMME'S OBJECTIVE
The need to follow up the graduates of this programme with evaluation studies focusing on their performance in their places of employment was identified by seven of the 13 respondents.Five respondents felt that an investigation into the students' own perceptions regarding their experiences and feelings of adequacy would reveal whether this objective was being met.

TEACHING AND LEARNING ACTIVITIES THAT WOULD FACILITATE OR HINDER ATTAINMENT OF THE PROGRAMME'S OBJECTIVE
The A number of aspects were identified as features that would hinder the attainment of this objective.Amongst others, these were (a) fragmented clinical placements, (b) emphasis on a number of lectures and clinical hours instead of competencies, (c) a packed and rigid curriculum with "too many nice to knows", and (d) enforced qualification in all four clinical areas.In fact one of the respondents had this to say:

DISCUSSION
The reasons, aims and expected outcomes of the CBNP as identified by the respondents did not differ from those appearing in South African nursing literature as well as those tabled by the SANC in the form of the objectives of this programme (R. 425 of 1985).
Although by the end of this phase, only 13 members were still participating, this is probably a representative figure for the leaders in this field.Firstly, the researcher had used a population of leading nurse educators in the country rather than a sample.
The SANC developers of the programme were asked to participate but chose not to.Therefore, it can be argued that the aims as identified by the participants in this study are the legitimate reasons, aims and expected outcomes of the CBNP., 1979, 41).In contrast, Viljoen (1989) suggested that the nursing colleges were in fact given too much freedom by the SANC.This dilemma pervades the professional regulating bodies of a range of professions (Levine, 1978).
Additional research is needed to examine the perceptions of the students and diplomates of this programme regarding their experiences both in classroom and clinical learning contexts.Some members of the panel recommended that a period of internship for the diplomates of the CBNP would help alleviate some of the problems experienced by these nurses on their first appointments as registered nurses.
Review of the national "basic standards" as well as local curricula may help rid the programme of some the areas seen as 'nice to knows'.The profession needs to re-examine the value it places on clinical teaching.This might necessitate total restructuring of clinical teaching posts so as accord the clinical instructor the same status as the tutor.In this way, this essential aspect of preparing individuals for professional practice might be treated with all the significance it deserves.Finally all those who are involved in the education of students need to be involved in curriculum planning and decision making at all levels of planning.
The development of the ability for analytical, critical, evaluative and creative thinking and the stimulation of the exercise of interpretation, deductionand independent judgement of scientific data for nursing actions are of utmost importance (Woodward, 1991,9).

The
the aims and anticipated outcomes of a programme that had succeeded in achieving the identified aims.For the second round of the Delphi, three rating scales were designed based on respondents' responses to the first questionnaire.Members of the panel were required to indicate whether they agreed or disagreed with the reasons and aims identified.Only those reasons and aims which were mentioned by two or more respondents were included in this round.This resulted in a five item five-point scale for reasons for the establishment of the CBNP and s 12 item five-point scale for the aims.The third rating scale involved rating of the identified expected outcomes as:-very important = Im p o rta n t; 1 = Im p o rta n t W B N = W o u ld b e n ic e il a c h ie v e d : Nl = N ot Im p o rtan t basic nursing • Yes.... Of midwifery I'm not sure.Experience seems to be lacking...Jn community health and psychiatric nursing competency is not reached to the effect that students can practice [sic] in this field especially not in primary nursing.Their diagnostic skills are too poor.

FEATURES
again are the problem.Promotion should be given according to merits in training involvement."The problem of outdated nurse educators in terms of developments in education was the only hindering factor identified by at least three respondents.ent o fa ll tutors that p a r ticipate in teaching o f students in the planning o f m icro-curriculum , and in tegration o f know ledge/skills by all tutors w ho participate in teaching in the p lanning and im plem entation o f the m icro-curriculum o f all subjects.

TABLE 1 Ratings of Aims of the CBNP by Leading Nurse Educators N = 13 (Second Round)
SA = Strongly Agree; A = Agree; N = Neutral; DA = Disagree; SD = Strongly Disagree responded to

the first questionnaire. At this stage, panel members were requested to respond to three rating scales. No attempt was made to follow up those subjects who had not responded to the first round of the study. Based on information obtained from the second round, a third instrument, together with a summary of findings of the second round data was mailed to the 16 panel members who had participated in the second phase of the study. Only 13 respondents completed this round. At this stage the number of panel members (13) who were still participating in the study had decreased remarkably. It was decided to terminate this phase of the study at the end of the third round for the following reasons: (a) the information obtained from this phase was deemed adequate as a basis for assessing the implementation process, at least in terms of which components of the CBNP were perceived as important, (b) responses regarding the nature of the teaching and learning activities that would hinder or facilitate attainment of the expected outcomes were stated in very broad and general terms in most cases, and therefore, did not provide any specifics in terms of what nurse educators should be doing in order to aid students' attainment of the expected outcomes. DATA ANALYSIS Data obtained from the three open-ended questions returned by panel members during the first round of the Delphi were analysed qualitatively. Depending on the nature of the responses, either sentences or paragraphs were used as units of analysis. Emphasis was mainly on contextual analysis which yielded 17 reasons, 23 aims and 24 expected outcomes for the CBNP. These aims and expected outcomes were further analysed quantitatively by means of frequency counts to identify items mentioned by more than one panel member. In all, five reasons, 12 aims and 10 expected outcomes were mentioned by more than one respondent. Second round data were analysed quantitatively in order to ascertain the level of agreement among panel members regarding the nature of the identified aims, as well as the degree of importance participants placed on identified expected outcomes. The open-ended responses obtained from the third round were analysed both qualitatively and quantitatively. Qualitative analysis of data involved categorising responses according to similar themes, based on both sentences and paragraphs. Focus was on contextual or whole meaning of respondents' statements. Where outlines were given rather than open ended statements, an attempt was made to classify these according to existing categories obtained through the analysis of the open-ended responses. FINDINGS NEED FOR THE CBNP IN SOUTH AFRICA Most (15) of the panel members who responded stated that there was a need for the comprehensive basic nursing programme in South Africa. The one respondent who did not believe that there was a need for this programme maintained that distinguishing devices accompanying course completion imply that the graduates of this programme are specialists in all four areas (general nursing, midwifery, psychiatric nursing, and community health nursing) whereas in actual fact "they are lacking in knowledge". REASONS AND AIMS FOR THE ESTABLISHMENT OF THE CBNP A total of 17 reasons for the need for the CBNP in South Africa was identified by respondents during the fust round but only five of these were mentioned by more than one member of the panel During the second round, unanimous agreement was reached on one reason only, namely the need to produce nurses capable of rendering comprehensive health care. Also, 11 of the 13 respondents who returned the second round questionnaires agreed that the need to integrate information and make nursing education more cost effective warranted establishment of the course. Consensus was reached by 50% of respondents on the need to shorten the period of nurse preparation as a reason for the establishment of the course. Various aims (23) were identified. Twelve (12) of these were mentioned by two or more respondents during the first round of the Delphi One aim viz. to produce nurses capable of rendering comprehensive health care to all patients and all clients was mentioned by 10 respondents in the first round. All respondents agreed with this aim in the second round. Ability to render comprehensive health care was rivalled by the need to produce nurses who would be able to render total patient care. A number of respondents (10-12) agreed that the development of (a) independent learning skills, (b) competence in cognitive, psychomotor, and affective skills, (c) ability to work as a member of a multidisciplinary health team, and (d) ability to think critically, creatively, and analytically, were aims. Table 1 depicts the 12 aims which were included in the second round. EXPECTED OUTCOMES OF THE CBNP The members of the panel identified 24 expected outcomes for the four year basic nursing programme. Of these 24 expected outcomes, 10 were mentioned by more than one respondent Not surprisingly, ability to meet comprehensive service needs by the graduates of this programme was the most frequently mentioned expected outcome. Four of the 10 expected outcomes included in
Curationis, V ol. 18, N o. 1, March 1995

TABLE 2 Ratings of Expected Outcomes of the CBNP by Leading Nurse Educators
N = 1 3