Nursing education, constraints, and critical consciousness: the birth and death of a Modellversuch in West Germany

This study is an analysis of the social, political, and economic factors that affect nursing education in the Federal Republic of Germany. The analysis was carried out through the examination of a specific situation, that is, the implementation of a university-based, experimental program for nursing instructors at the Free University of Berlin from October 1976 through June 1982. The study is presented as a 'problem-posing' work to stimulate dialogue in the Federal Republic of Germany--and other countries--about the means and ends of nursing education and to outline a nursing education that is 'freeing,' that is, that leads to the development of critical consciousness. Faculty members of the experimental program and government officials were interviewed, reports of the project read, and the literature reviewed to gain insight into the factors leading to the conceptualization of the program and its noncontinuation. A hermeneutic-dialectical method of inquiry and analysis was employed, in which the meaning of the events to the participants was sought, and the contradictions in the situation brought to the surface. The data analysis revealed that on one level there were political and economic reasons for the program not being established as a permanent course of study at the Free University, but, at a deeper level, it was an oppressive act toward the nursing discipline to prevent its entrance into the realm of university education. Jurgen Habermas' critical social theory and Paulo Freire's model of oppressed group behavior and a pedagogy of the oppressed were reviewed to provide the theoretical underpinnings for dealing with a situation of oppression in order to determine ways to transcend it. Based upon these constructs, the characteristics of an education that is 'freeing' were outlined and related specifically to the realm of nursing. This was based upon the belief that it is only through the shedding of false consciousness imposed upon individuals that they will be able to clearly see reality and intervene in its course to bring about a situation that is less constraining, that is, more 'freeing.'

NURSING EDUCATION, CONSTRAINTS, AND CRITICAL CONSCIOUSNESS: THE BIRTH AND DEATH OF A MODELLVERSUCH IN WEST GERMANY by Barbara Ann Scheller Hedin A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing The University of Utah August 1985 THE L')\'I\'ERSITY OF L'TAH GRADL'ATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a dissertation submitted b\ Barbara Ann Scheller Hedin This dissertation has been read b\ each member of the following superYison committee and b\ majority vote has been found to be satisfactory, ChaIrman: //) , ./ .•.. :£ (/ Ih 4~ter C. M~rley~--7 I I Joy C. Clausen f ,/ / g4:~ Walter Hahn - (/ v ] I ')~ !' I.e i,( ' //L)7 _ 1_1 !..·sc'i, /- <~ 1 At! !/Iw!6!/ /~ ____ ~~~~-L~~~~~=-__________ __ Sue E. Huether \ John S. Packard THE Ll'l\'ERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: Ihavereadthethesisof Barbara Ann Scheller Hedin inits final form and have found that (I) its format. citations. and bibliographic style are consistent and acceptable: (2) its illustrative materials including figures, tables. and charts are In place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. -' ale I 7 ( Peter Member. Super\ tsor: Commlltee APpro~~v~~e thde~ M ajor oer::part\ment "--. . '1: - .' / I . '. .." ....-./VL{';vJ Linda K. Amos, F.A.A.N. Cnairman Dean Approved for the Graduate Council Copyright © Barbara Ann Scheller Hedin 1985 All Rights Reserved ABSTRACT This study is an analysis of the social, political, and economic factors that affect nursing education in the Federal Republic of Germany. The analysis was carried out through the examination of a specific situation, that is, the implementation of a university­based, experimental program for nursing instructors at the Free Univer­sity of Berlin from October 1976 through June 1982. The study is presented as a IIproblem-posingll work to stimulate dialogue in the Federal Republic of Germany--and other countries--about the means and ends of nursing education and to outline a nursing education that is IIfreeing,1I that is, that leads to the development of critical consciousness. Faculty members of the experimental program and government officials were interviewed, reports of the project read, and the literature reviewed to gain insight into the factors leading to the conceptualization of the program and its noncontinuation. A hermeneutic-dialectical method of inquiry and analysis was employed, in which the meaning of the events to the participants was sought, and the contradictions in the situation brought to the surface. The data analysis revealed that on one level there were political and economic reasons for the program not being established as a permanent course of study at the Free University, but, at a deeper level, it was an oppressive act toward the nursing discipline to prevent its entrance into the realm of university education. Jurgen Habermas' critical social theory and Paulo Freire's model of oppressed group behavior and a pedagogy of the oppressed were reviewed to provide the theoretical underpinnings for dealing with a situation of oppression in order to determine ways to transcend it. Based upon these constructs, the characteristics of an educa­tion that is "freeing" were outlined and related specifically to the realm of nursing. This was based upon the belief that it is only through the shedding of false consciousness imposed upon individuals that they will be able to clearly see reality and intervene in its course to bring about a situation that is less constraining, that is, more "freeing." v ABSTRACT PREFACE INTRODUCTION . . Notes TABLE OF CONTENTS PART ONE THE DATA SPEAK I. LINEAGE: THE HISTORICAL CONTEXT OF THE MODELLVERSUCH Structure of the West German Education System . . . . Historical Development of German Nursing and Nursing Education . . . . . . . . . . . . . . . . . Notes II. BIRTH: CONCEPTUALIZATION OF THE MODELLVERSUCH Conceptualization of Three-year University Courses for the Health Professions .......... . Conceptualization of the Modellversuch at the Free University of Berlin ............... . An Elaboration of the Social Context. . .. . Notes . . . . . . . . . . . . . . . . III. LIFE: IMPLEMENTATION OF THE MODELLVERSUCH . The Planning Phase .......... . The Implementation Phase ........ . The Evaluation Phase .......... . Additional Comments on Evaluation Procedures Notes . . . . . . . . . . . . . . . . . . Page iv ix 4 6 7 23 54 60 61 68 72 79 82 82 97 116 117 119 IV. DEATH: NONCONTINUATION OF THE MODELLVERSUCH . . 122 University Actions in Support of the Modellversuch 123 The Nature of the Modellversuch . . . . . . . . . 124 Noncontinuation of the Modellversuch: From the Perspective of Its Staff. . . . . . . . . . . 128 Noncontinuation of the Modellversuch: From the Perspective of the Land Government. 147 Notes . . • . . . . -. -.-. . . . . . . . . . . . 156 PART TWO DIALOGUE WITH THE DATA Page V. POSTMORTEM: NURSING EDUCATION, CONTEXT, AND SOCIAL VI. CONSTRAINTS IN THE FEDERAL REPUBLIC OF GERMANY. . 159 Analysis of the Factors Affecting the Conceptualiza-tion of the Mode11versuch . . . . . . . . . . . . 161 Contradictions within the Implementation Phase of the Mode11versuch . . . . . . . . . . . . . . 167 Factors Affecting the Noncontinuation of the Mode11versuch . 170 Concluding Remarks. . . . . . . . . . . . . 179 Notes . . . . . . . . . . . . . . . . . . . 182 FREIRE AND HABERMAS; GOOD LIFE .... CRITICAL CONSCIOUSNESS AND THE Critical Social Theory ... A Pedagogy of the Oppressed Concluding Remarks ..... . Note s . . . . . . . . . . . 183 186 197 216 218 VII. REGENERATION: NURSING EDUCATION AS FREEING 220 Nursing as an Oppressed Group in West Germany 221 Nursing Education as Freeing . . . . . . . . . 235 Beginning Thoughts on a Nursing Education that Is Freei ng . . . . . . . . . . . . . . . . . . 238 A Nursing Education that Is Freeing and the Social Context 250 Notes . . . . . . . . . . . . . . . . . . . . . . 253 Appendices A. GLOSSARY OF GERMAN WORDS B. SOURCES FOR PROBLEM LIST IN CHAPTER I C. GLOSSARY OF GERMAN PROPER NAMES ... D. SELECTED LISTING OF SOURCES OF DATA FOR CHAPTERS II THROUGH IV . . . . . . . . . . . . E. METHOD AND METHODOLOGY OF THE STUDY F. TIMELINE OF THE MODELLVERSUCH . vii 255 258 261 265 268 275 Appendices Page G. REPRESENTATIVE COURSES TAUGHT WITHIN THE VARIOUS MAJORS OF THE MODELLVERSUCH . . . . 277 H. STATES OF "BEING IN THE WORLD" 281 SELECTED BIBLIOGRAPHY 289 viii PREFACE During a three-year experience of living in the Federal Republic of Germany--from 1974 through 1977--1 found that my horizons and view of the world were much expanded through the experience of living in another culture and encountering different ways of dealing with the same issues encountered in the United States. When attempting to decide among the many possibilities for a dissertation topic in the field of nursing education, this experience came back to me, along with the thought that, if general horizons could be broadened through exposure to other cultural contexts, so too could the same occur with­in a specific area such as nursing education. Through comparative nursing education research, insight into alternate ways of dealing with the problems and issues confronting nursing could be achieved. Many could benefit from such an endeavor of collaborative research across national boundaries. Because of previous living experiences in the Federal Republic of Germany (FRG), a beginning knowledge of the German language, and some familiarity with the West German culture, I decided to engage in a research project in that particular country. An additional reason for choosing the FRG as a study site was that it too is a Western, industrialized nation, and it was hoped that the nursing situation in that country might mirror the situation in the United States. Thus, Americans might not only learn about another nursing education system but also might see their own situation reflected in the study, gain insight into their actions, and acquire possible alternatives for the future. The conduct of the study can be divided into four phases. During Phase I of the study, which lasted from June 1982 to December 1983, I concentrated on improving my language skills and increasing my knowledge about nursing and the nursing education system in the Federal Republic as well as its general social and political context. Intensive German language instruction was taken in the summer of 1982, winter 1983, and summer 1983. At the same time interviews were con­ducted with hospital nurses, instructors of nursing, and nursing school directors to learn about the functioning of their health care system. Extensive reading was done in German history as well as in its nursing literature. Individuals interviewed were asked about problems facing West German nursing to insure that the topic chosen for the study would be relevant to the West German nursing scene and not merely to the interest of the researcher. Toward the end of this period time was spent in the United States reviewing this information and writing the research proposal. Phase II began upon my return to the Federal Republic in January 1984 and extended to April 1984. At this time the proposal still stated the research focus in a rather general way, that is, lithe analysis of social, political, and economic factors that affect the nursing education system in the FRG." While I had a fairly definite idea of which specific questions would be necessary to x explore this, I wished to discuss these further with West German nurses. It was during this time period that these discussions were conducted and the focus changed to that which was actually studied. During Phase III of the study, from April 1984 through September 1984, the data for the study were collected. Numerous other things also occurred at the same time. From March through July 1984 I studied German and attended two seminars at the University of Kiel in north Germany. It was an opportunity to experience the West German university system firsthand and to be totally immersed in West German life. Not only were the interviews conducted which pertained to the research topic directly, but also others with nurses in education, the trade union, and other leadership positions throughout the FRG. Several continuing education conferences for nurses were attended during this time to gain insight into their current interests. I was a member of the German Nurses Association for the duration of the time spent in the country and subscribed to two of the West German nursing journals. During Phase IV of the study, November 1984 through April 1985, the data were analyzed and interpreted. An ongoing dialogue has been maintained with individuals in the Federal Republic who continue to discuss questions that arise, clarify issues, and review written work. In such a study as this, when I was, figuratively speaking, standing with my feet in two countries, there are individuals to be acknowledged for their support, guidance, and patience, too numerous xi to be named. First and foremost my thanks goes to the members of my Supervisory Committee for their faith in me throughout this process, and especially to Peter Morley, who chaired the committee, and John Packard, who nurtured this project from its earliest stages to its completion. Considerable time spent outside the United States meant that colleagues in Utah needed to mediate bureaucratic details, supply me with reference materials, and maintain communication channels. While many people shared in this chore, Margaret Andrews deserves special mention. In the midst of writing her own dissertation, she fulfilled my unending requests for assistance at the most inopportune times. It would be difficult to mention all the persons in the FRG who made this study possible through their constant support, unend­ing patience in answering questions, helpful suggestions, and honest critiques of my work. I especially thank Antje Grauhan for her time, patience, and encouragement in this endeavor. Finally, there are no words to express the importance of the support and understanding of my husband, Nyle, who sometimes looked on in puzzlement as I tripped between the United States and West Germany, never asked how soon I planned to finish this project, and, in self­defense, perfected his cooking skills to those of a gourmet cook. To say that the dissertation was written by myself means exactly that. However, it is an illusion to think that one person alone conducts a study; research is one of the most collaborative and participatory experiences in which a person can engage. xii I NTRODUCTI ON In the fall of 1976 the Free University of Berlin was informed by the Federal-States-Commission for Educational Planning that the university1s proposal for an experimental program, IIModellversuch: The Development and Testing of a Three-year Course of Study for Instructors in the Health Professions ll (hereafter referred to simply as the IIModellversuch ll ), had been approved for funding. The planning phase was scheduled to begin in October 1976 and the evaluation phase to conclude in September 1981. The broad goal of the program that was planned and implemented as a result of this proposal, stated in its most general terms, was to lead to lasting improvements in nursing practice which would posi­tively influence professional satisfaction and motivation in the nursing discipline. There was widespread agreement among West German nurses that the existing basic and postbasic nursing education system had numerous shortcomings. Planners of the Modellversuch sought to effect a change in the education of instructors of nursing with the expectation that improvements in the basic nursing education would follow. By incorporating nursing as a university program, the goals of a university education, that is, education of the whole person, and the development of critical thinking skills were sought by (and for) nursing. Three fundamental principles guiding curriculum planning for 2 the Modellversuch were (1) the orientation of all courses on nursing practice, (2) emphasis on a patient- and personnel-oriented nursing care, and (3) openness of the curriculum. Students in the Modellversuch had three study focuses: education; nursing, which was the first major; and a second major, to be chosen from the fields of biological-medical principles, social science principles, and principles of health affairs. Each of the three areas--that is, education, nursing, and the second major--were equally weighted in the curriculum. The students were to achieve cer­tain competencies: (1) the ability to give practice-oriented instruc­tion, (2) the ability to give clinical and theoretical instruction in nursing and in an area of a second major, (3) the ability to criti­cally examine scholarly and practice-related research results, and (4) the ability to give exemplary nursing care. While the idea of university education in nursing was not new to the nursing world in October 1976, it was the first time in West Germany that nursing was to be the subject of a university course of study with a university degree (the Diplom)l awarded upon completion. Twenty-eight students completed the six-semester, three-year, experimental course of study in September 1981. Over one hundred more applicants awaited acceptance into the program for the fall of 1982, should it be instituted as a permanent course of study at the Free University. By 1985, there were again no university courses of study (Studiengange) for nurses in the Federal Republic of Germany. In a world in which at least some nursing education occurs at the 3 university level in many European countries, the Anglo-saxon countries and even some Third World countries, it stands out that the West German nursing education takes place completely outside the univer-s ity system. What the factors were effecting this situation and how nurs-ing, through a nursing education that is "freeing," that leads to the development of critical consciousness, can transcend societal constraints is the subject of this paper. As such, the paper is written as a problem-posing work to aid dialogue and critical reflection on the ends and means of nursing education in the FRG as well as in other countries, for which the Federal Republic can serve as a mirror of the times. 4 Notes lWhile referred to by some authors as a university degree, perhaps a more correct rendering of the term "Oiplom" would be "state certification based on academic training." The reader is referred to Appendix A for definitions of German words used repeatedly throughout the text. PART ONE THE DATA SPEAK CHAPTER I LINEAGE: THE HISTORICAL CONTEXT OF THE MODELLVERSUCH Before reporting and discussing the data on the history and noncontinuation of the Modellversuch,it is essential to discuss the context within which it originated. The historical, political, and socioeconomic context is somewhat problematic, in that the research was conducted in West Germany, a culture foreign to the majority of the readers of the study. This necessitates a detailed introduction to the West German education system in general and the nursing educa­tion system in particular including the historical development of the latter. A contextual understanding is of great importance for two reasons. First, all people have some basic assumptions and preunder­standings about the world which shape their actions and judgments. If it is not clear that a situation is different from that which they normally encounter, these preunderstandings will be operative in their reaching certain conclusions about a situation or event. Hence the importance of presenting this contextual background early in the paper prevents this from occurring, or at least minimizes its effects. Second, if the reader is to judge whether the interpretations drawn from the data in later chapters are valid, then enough informa­tion must be made available for such a judgment. While it is 7 preferable to interweave the contextual background information with the data presentation, and thus to avoid the illusion that objects can be understood apart from their contexts, such a style of writing creates a narrative that is difficult to follow. Therefore, a compromise position is used. The general education system and the nursing education system are outlined in this first chapter, and other political and socioeconomic contextual information are inter-woven throughout the paper, along with more detailed information on the educational and nursing areas. Structure of the West German Education System Establishment, Control, and Coordination The critical problem facing Germany in reestablishing its education system after the Second World War was the avoidance of the authoritarianism of the Third Reich on the one hand, and chaotic fragmentation on the other. Under the four-power control and occupa-tion of Germany from 1945-1949, all ied intentions were that "German education shall be so controlled as to completely eliminate Nazi and militarist doctrines and to make possible the successful development of democratic ideals."l How this was to be specifically accomplished was a subject of varied interpretation and much controversy, although most parties agreed that a decentralized system was the key. The 1949 Constitution of the Federal Republic of Germany delineated the control mechanisms governing the education system. Article Seven states that (1) the entire education system will be 8 under the supervision of the Lander;2 (2) religious instruction will form a part of the curriculum in state schools, though parents shall have the right to decide whether their children shall participate in it; and (3) private schools must have a state license, and this will be granted only if (a) the curriculum conforms to the same basic minimum requirements as state schools, (b) the academic staff is com­petent and qualified by state standards, and (c) the wealth of the parents is not a criterion for entry.3 The result has been that only a negligible percentage of the primary and secondary institutions in West Germany are privately controlled, and that all universities until the early 1980s were state controlled. Control of education in the Lander occurs through three levels of administration: (1) the State Ministry of Education, (2) the Government-District (Regierungsbezirk), and (3) the county level. 4 Notably, the Lander have been the most important originators and initiators of change in education in West Germany. Changes initiated in particular Lander are often picked up in other parts of the country. The postwar policy delegating educational matters to the Lander led to certain problems. There were troublesome inconsistencies between Lander policies and an inhibiting effect on inter-Lander mobility, due to reluctance to recognize qualifications acquired in other Lander. In recent years the federal government has become an indispensable partner in the domain of education. Subsequent con­stitutional amendments have increased the federal government's role in financing certain sectors of education and research through attempts 9 to equalize somewhat the financial burdens between economically stronger and weaker Lander. In addition, the federal government has assumed broad planning and coordination capacities. This increasing federal involvement is approached with much caution on the part of the Lander. Federal responsibilities in education are handled through several bodies, including the Council for Research and Technology,5 the Federal Ministry of Education, Arts, and Sciences, and the Stand­ing Conference of the Ministers of Education and Cultural Affairs. The latter deals with cultural and educational matters of supraregion­al importance; it is known for its conservatism in planning and policy making due to the requirement for unanimous agreement to pass a recom-mendation. An advisory body that has proven to be quite effective in initiating change in the West German education system is the Council for the Arts and Sciences (the Wissenschaftsrat), which has been in existence since 1957; it is composed of a balanced membership repre-senting the Lander, federal government, universities, and industry and commerce. While only a recommending body in the area of higher educa­tion, it was effective in initiating education reforms in the 1960s and 1970s, and has been credited with the establishment of the advanced teaching- and research-oriented University of Constance and the large-scale employment of faculty below the rank of full professor through its recommendations. The German Education Council is similar to the Wissenschaftsrat except that the areas of primary and secondary education are its domain. It has played an important role in the 10 reform of teacher education in Germany. Among these various coordinating and planning bodies. perhaps the most important is the Federal-States-Commission for Educational Planning (Bund-Lander-Kommission fUr Bildungsplanung). It was organ­ized in 1970 and is the umbrella organization for educational policy making in all sectors. It is in charge of long-range development planning for the entire education system, and takes into account the recommendations of the various advisory bodies. Its major achievement was the 1973 Comprehensive Educational Development Plan (Bildungsgesamtplan), which was West Germany's first comprehensive. goal-based. long-term development and reform program for all areas of education. Overview of the German Education System The West German education system is without cost to the stu-dents at all levels, primary through university. After World War II the framers of the German constitution were concerned that cost not be a barrier to anyone seeking an education and that there would be equal opportunity for all citizens to obtain a qual ity education. Preprimary and Primary School Education Kindergarten. Kindergartens in Germany are outside the official organized state system of education; they are normally run by welfare organizations, churches. the local authorities, industry, or private managers. A fee is required but often waived if the family cannot afford it. 11 Grundschule. The primary school (Grundschule) is the founda-tion for all further education. Its aim is to recognize, cultivate, and develop a child's natural gifts and to give thorough instruction in the essentials of a good general education. Specifically, its goals include the following: ... confident oral and written use of the mother tongue; assurance with figures; familiarity with the objects and workings of nature; appreciation of poetry (and the arts in general); a sound religious grounding; [and] a knowledge of history that will gear itself clo~ely to the study of the workings of a democratic society. In most Lander the primary school encompasses the first four years of study, beginning at age six; the exceptions are in the city-states of Hamburg, Bremen, and West Berlin, where it may encompass six years. (See Figure 1, Educational Facilities in the Bundesrepublik, for additional clarification throughout this section.) Secondary Schools There are three types of secondary schools in West Germany: the Hauptschule, the Realschule, and the Gymnasium. Hauptschule. The Hauptschule is the upper primary school, which includes grades five through nine; well over 50 percent of those in the ten to fifteen year age group attend this type of school, and the percentages are higher in the rural areas. 7 The progression from the Grundschule to the Hauptschule is automatic, and the two together are sometimes referred to as the Volksschule. The Hauptschule offers a practical education and tends to suffer from an "image problem," in that the students attending this school are some-times held to be unqualified for either of the other secondary -... u -=' GO ~ u GO ~ -GO ~ co 2 1 e ~ 6 Q.. ~ co 5 .. >. C> 4 C> ~ u en 3 mn ~ ~ I] A bendrea Is c h u Ie I-gym Ko Ileg D~~a.c~~ Berufsaufbauschu Ie Ki ndergar ten (full-time or port-time 11/2-3years) Fachschule (11/2-3years) erufsschule (port -ti me) Pre-primary Leaving certificates: Primary o. Hauptschule Secondary b. Realschule or equivalent (general & technical) (Fachschulreifel Secondary (vocational) c. Fachhochschulreife T e rt i a r y d. Ab i t u r 12 Figure 1. Educational facilities in the Bundesrepublik. SOURCE: Gunther Kloss, West Germany: An Introduction (London: The Macmillan Press, 1976), p. 116. Reprinted by permission. 13 programs. Realschule. The Realschule, or Mittelschule, is the inter­mediate school and offers a six-year education, from grades five through ten. It offers a general education beyond the elementary level for those students who show promise but are not the "cream of the crop" for the Gymnasium. Usually one or two languages are taught and the aim is to educate skilled craftsmen, minor civil servants, and individuals who will be employed in trade, industry, or commerce. The Realschule completion certificate, the Fachschulreife or the mittlere Reife, qualifies the student for higher education but not for university attendance. This certificate is the present educational requirement for admission to nursing school. Gymnasium. The Gymnasium has a nine-year course of studies for grades five through thirteen and is the only route to a university education. The purpose of a Gymnasium education is to educate the future leaders of the country through providing a complete introduc­tion to scientific and scholastic thought, widening the intellectual horizons of its pupils, and teaching discriminating judgment.8 There is generally a six-month to two-year observation period in the Gymnasium during which students who are not able to perform to stan­dards may be transferred to the Realschule. Successful completion of a state examination, the Abitur, at the end of Gymnasium study guar­antees one a study place in a German university. At the end of the primary education the parents usually decide with the teacher which type of secondary school a child is best suited for. There is concern that this process maintains the current 14 elitist structure and does not stimulate interest among lower-class families in Gymnasium education for their children. Other criticisms of this system focus on the early decision--when the child is only ten years old--regarding the child's suitability for higher education. In the past several years, efforts have been made to introduce an orientation level into the secondary education which would be common across all the schools and allow for mobility among them (see Figure 1; note specifically the "Orientierungsstufe"). In another effort to increase flexibility and mobility, there has been a move to establish Gesamtschulen (comprehensive schools). In this setting all three types of secondary schools are located under one roof or--depending on the pattern chosen in a given state or school--there is an inte­grated program, at least through the tenth year of school, that is, until about age sixteen. To give options to those who left school after the compulsory minimum but later wish to study at the university, Abendgymnasium or Abendrealschule (evening schools) have been estab­lished to prepare individuals to take the Abitur. Kollegs, full-time, day programs--not to be confused with American colleges--also provide a "second road to education" (zweiter Bildungsweg) for these individuals, as do correspondence courses, some of which are conducted in conjunction with television courses. 9 It might be said that secondary education in West Germany is thorough, comprehensive, and highly specialized. It seeks to provide an educated populace at all levels: academic, commercial, and techni­cal. 1 5 Postsecondary Education Beyond the completion of the compulsory education of the secondary schools, students normally continue either in higher educa­tion institutions (Hochschulen) or in one of the vocational or technical schools. Although in some areas the line of separation is quite indistinct between the two kinds of postsecondary education, vocational and technical education are not considered part of higher education per se. Following the completion of Hauptschule, students generally attend a part-time vocational school (Berufsschule) for several years, one or two days a week on a day release program. The purpose is to enrich and supplement practical apprenticeship training, to promote professional training, enlarge and deepen general know­ledge, and to educate the individual to be a valuable member of society.10 Besides part-time attendance at a vocational school while working, full-time attendance is also an option (Berufsfach­schule). Nursing education fits most closely though not exactly, in this category of education. These schools may be operated by the local community, by vocational organizations, or privately. There is much variation in these programs. One receives a general education up to the standard of a Realschule leaving certificate in such areas as commerce, industry, home economics, fine arts, and language. Following attendance at one of these schools and with sufficient practical experience in a vocation, one may opt to attend an advanced technical school (Fachhochshule), some of which have been upgraded to the level of higher education institutions, particularly in the area of engineering. 16 Higher education. All institutions of higher education are grouped together and referred to as Hochschulen in West Germany. There are three basic types of higher education institutions: advanced technical colleges (Fachhochschulen), advanced professional colleges including those for teacher preparation (Padagogische Hochschulen), and universities. The advanced professional colleges are academically approved by the state and the graduates are considered gradiert but do not receive the Diplom as awarded by the university. The Diplom is the first academic degree awarded by the university and takes from four to six years for completion. The Diplom is awarded by the university upon completion of studies and comprehensive examin­ations (most often both written and oral). University completion is not a guarantee for a job; successful completion of the Staatsexam, exams given by the state, qualifies one for a government position. The Doktor is the second academic degree, which may take an additional four to seven years for completion. As a result of the 1976 Federal Coordinating Law for Higher Education (Hochschulrahmengesetz), there is a movement in some quarters toward development of comprehensive higher education institu­tions (Gesamthochschulen) which would unite all higher education institutions in one area into a super university. Academic work currently offered at different institutions in one locality would be coordinated and perhaps administered by one body. The effects of this development remains yet to be determined. Problems of Postwar Changes in the University System 17 Because the Modellversuch which occurred at the Free Univer-sity of Berlin took place in a university setting, and because an understanding of the background events leading to its establishment are intimately related to calls for reform, it is necessary to dis-cuss the university education system of West Germany in more detail. Rebuilding the German University after 1945 At the end of World War II, German education was in a state of physical and intellectual ruin. Many libraries and laboratories were destroyed; of twenty-three universities located in Germany, only nine were relatively unharmed. ll By 1946, however, all had reopened. Reforms are to be expected during periods of rebuilding, and the allies attempted to bring about changes during the occupation period. However, they could not agree on specific reform policies. In fact, the dependence of the Germans on the allies for approval of any proposed changes actually inhibited reform. There are a number of other reasons given for this lack of reform at a time ripe for such possibilities: (1) preoccupation with the problem of merely subsisting from day to day; (2) enthusiasm for any intellectual pur-suit after its long suppression, rendering any interest in reform secondary; (3) yearning for the "good years" before the war; and (4) reliance on traditions encouraged by the loosening of ties to a central authority.12 As a result, the rebuilt education system was a replica of 18 the university model conceived by Wilhelm von Humboldt in the early nineteenth century. The following description of the German univer­sity in 1966 could have been written in 1890: The chairman is often the only tenured and full professor in a department. He is appointed for life and functions as a one-man dissertation and licensing committee since the granting of the German university degree is congruent with certification ... the German Doctor of Philosophy remains an assistant to his professor for about 6 years. After this period, he writes another dissertation, the "Habi1itationsschrift," for which the chairman's approval is again needed ... he often has little choice in the initial subject selection and in the methodology of his work. The chairman's power reaches beyond the department, especially through his various editorial positions. This dual authoritarian role stifles many young researchers and undoubtedly hinders new avenues and approaches. Papers by the chairman or those which have his approval are usually published without further scrutiny, or style and length restrictions. This does not necessarily contribute to the clarity of the writing. The authors' names are never omitted during selection procedures, but form an important selection criterion. The one-man decision cuts committee work and pub­lication lag, but seems to invite bias and hinders criticism within many specialized areas. 13 At the close of the 1960s, two thirds of all departments were still headed by a single Ordinarius (the full professor described above). This "museum piece" collapsed at the close of the 1960s, which opened for the first time in 150 years the possibility for real change. The enlightened Humboldtian university was unable to cope with the need for mass education required by a modern Western indus-trialized nation and an era came to a close. The Federal Coordinating Law and the Beginning of Reform After considerable political infighting and bargaining, the Federal Coordinating Law for Higher Education (Hochschulrahmengesetz) was passed 26 January 1976. While permitting the Lander to retain 19 significant power over the universities, the changes suggested by this law are revealing. The law resulted in the first structural changes in the German university since the nineteenth century. Major features of the law included the following: (1) Universities are to coor­dinate within Lander with all other postsecondary institutions; this may be done through integrated coordination, where the links are organic and functional, or cooperative coordination, where the links are primarily consultative. (2) The basic organizational unit will be the disciplinary department (Fachbereich). Departments replace in­stitutes, and the collective professoriate replaces the Ordinarius. (3) Academic committees are to allow for representation by professors, students, assistants, and other professionals; however, professors will retain a 51 percent majority. In votes on curricular matters and academic expenditures, a majority of the professors must agree. (4) The university must be headed by a full-time administrator elected by the university, with state approval for a minimum four-year term; but, if they so choose, they may retain governance by the traditional council as long as one member is designated the full-time administra­tor. 14 The purpose of the Federal Coordinating Law (sometimes also referred to as the "Framework Law" since it was the law on which the various Lander were to model their more detailed legislation) was to provide a certain uniformity in higher education across the eleven Lander. Although much diversity still remains among the universities, this law was a step toward some change within higher education palatable to all concerned. This law was the result of almost ten 20 years of negotiating and debate. The political leanings of the party in power in federal government and in Land or state governments, as well as the character and wisdom nf the Ministers of Education of the Lander, had a great impact on the nature of the universities in the various regions. Continuing Calls for University Reform High enrollment problems. Between 1950 and 1970, university enrollments in West Germany tripled and are still increasing. In 1968, there were 85,000 first-semester students; in 1973, 160,000; and in 1978, 236,000. 15 There are several reasons given for this increase. Not only is an increase in the population in this age group cited, as well as an increase in the numbers of students completing studies at the Gymnasium and successfully passing the Abitur, but also the increased length of study time at the universities. In 1968, the average length of study was 5.5 years; in 1972, 6.6 years. 16 Reasons given in a government study for this lengthened time included fear of examinations by students who still felt unprepared after four years, outside employment decreasing study time, and poor planning of aca-demic coursework. Some students stated that they had planned from the outset of their study to take longer than four years. This continuing increase in the student population is creating severe problems for the universities. One approach to the problem has been the application of the Numerus clausus, a restriction on the number of qualified applicants which can be admitted to some academic disciplines, especially to such areas as engineering, medicine, 21 dentistry, and pharmacy. The Numerus clausus is considered a temporary measure; it is alien to the German tradition and the consti­tutional intent of making higher education available to all who successfully complete the Abitur. Changes in admission criteria. In a country in which almost all universities are state controlled, there are no alternatives for university education for those performing poorly on the Abitur. Admittance to a university is dependent upon successful completion of the Abitur, an extensive examination given for most students at the end of thirteen years of schooling at about age nineteen. The grade average on the Abitur is generally the sole criterion for acceptance for about 60 percent of the applicants; and a combination of this with the seniority of the application is considered for another 40 per­cent. 17 While no suggestions for a different approach have been made, there are those who think that basing university admissions on the Abitur is unfair; it favors the wealthy who can afford tutoring after school or an extra year at the Gymnasium. Summary While the West German education system is similar to the American system in terms of its decentralization, the government in that country plays a much greater role in the control and financing of the education than is found in the United States. Following World War II, the occupying powers intended to guarantee that education would be decentralized with the locus of decision making at the Land level; this was effected but problems of a lack of coordination between Lander ensued as well as varying abilities on their part to finance the education. Hence there has been a trend 22 of increasing federal government financing and regulation of educa­tion, particularly at the higher education level. As a result, reforms are written into the laws, and such changes may exert a more lasting effect than in the United States and at the same time be less open to subsequent revision. A significant characteristic of the West German system is that it is at no cost to the students in order to assure an equality of educational opportunity for all. Also of note is the almost exclusively public education system that is in place in that country; there are few private schools and only in the early 1980s did the first private universities appear, which number only two or three at the present time. The progression of students through the West German educa-tion system is also quite different from the American system. After primary school, students are tracked into either a five-, six-, or nine-year secondary school, all of which have differing completion certificates and varying opportunities for further education. Only those students who have studied nine years at the Gymnasium and suc­cessfully completed the state examination at the end of this schooling, the Abitur, are eligible for university study. While reforms introduced in the 1960s and 1970s in West Germany sought to introduce more flexibility into the education system at both the secondary and higher education levels, rigidity remains in both with minimal mobility between the three tracks. Since the education is regulated by government legislation, changes are a slow and political process. Historical Development of German Nursing and Nursing Education Introduction While the early roots of nursing and the concept of caring 23 can be traced back to the ancient Egyptian, Roman, and Greek times, this section focuses on those more recent historical events which have had a perceptable impact on the development of nursing and nursing education as they exist today in the FRG. 18 The majority of histories written about German nursing locate the roots of modern nursing (die neuzeitliche Krankenpflege) in the midnineteenth century. Consequently this discussion begins there as well. This section presents the historical information from the perspective of various German historians. What follows is their view of the factors that have affected the development of nursing and nursing education in that country.19 The Nineteenth Century There is hardly an element in our present-day political, social, and scientific structure that has not been influenced by the events of the nineteenth century. 20 Social developments in the nine-teenth century were deeply influenced by both the thoughts of the French Revolution (1789) and the results of increased industrializa-tion. Freedom, equality, and national independence were the ideals sought by Europe and the rest of the world. With revolutions demand-ing democracy, the developing class struggle was the sign of growing 24 social conflict. While the population of Europe had remained fairly constant from the eighth to the eighteenth century, it increased five-fold within the nineteenth century. 21 This, coupled with industrial-ization and the appearance of large cities, led to the development of a new lower class whose living conditions were often deplorable. The center of life moved from the family and home to the factory and public arena. The railroad, steamship, and telegraph connected countries and the continent. The IIgreat powers ll expanded their con-trol to overseas colonies, and nationalism promoted economic and political rivalries paving the way for new wars. Religious ties gave way to the belief in the progress of civilization, enlightened reason, and science. Against this background, German medicine made revolutionary changes as it entered the phase of scientific medicine--that is, the practice of medicine based on scientific methods and research--follow-ing the lead of medical schools in Paris and Vienna. Correspondingly, nursing underwent a reformulation of its organizational structures in response to the new demands placed upon it by medicine and society. Anna Sticker, an important historian of German nursing, states that the changes of the nineteenth century demanded a transformation of nursing from lIa waiting on ll or lIobserving of the ill II (Kranken­wartung) to IIcaring for the ill II (Krankenpflege) ;22 the latter conveys a more active role by the care giver. The comments of Eduard Seidler, a medical historian who has written extensively about the history of medicine and nursing in Germany and on the causes of these changes are also quite revealing. He says that the forces for innovation in 25 nursing did not derive chiefly from the realms of medicine and caring, but, more importantly, from the spirit of intellectual and social upheaval of the times. In addition to the radical changes in medicine which placed new and scholarly demands on nursing, other important stimuli for change in nursing in this century were the willingness of women to work for the public good (offentliche Dienstwille der Frau), wars, nationalism, the question of the position of women in society, and emancipation. Kruse, in her dissertation on the historical development of German nursing education, concurs with this, pointing out that the initial burst of reform in nursing did not come from physicians and medical science but rather from theologians, the religious orders, women's groups, and the structures and institu-tions emerging from these, for example, the Mother Houses and nursing associations. 23 The roots of the four fundamental organizational structures of German nursing: the Catholic orders, the Evangelical Diakonie, the secular Mother Houses and "nursing as a profession" (freiberufliche Krankenpflege)24 will be explored in this section. Nursing within the Religious Communities Catholic orders. The traditional religious orders were eliminated during the 1789 Revolution in France. However, when Napoleon saw the oppressive conditions in the French hospitals, he permitted the reestablishment of female charitable orders (the Sisters of Mercy) with his full protection and support. 25 New congregations spread rapidly throughout Europe and overseas. In the early decades of the nineteenth century three of these branches were very important 26 in setting the foundation for future developments in nursing in Germany. Their significance in the care of the ill in Germany was furthered during a cholera plague in 1831 in which two books were written about their dedicated service. 26 The books led to a further renewal of Catholic welfare institutions and raised public health measures as an issue. The actions of these Catholic orders were faithful to the traditions of the old religious communities and brought no real reforms in the care-giving activities, the structure of the orders, or the education of those responsible for giving the care. Their efforts were limited to the realm of the cloisters or the hospitals operated by these orders. 27 A further limiting factor was that admission was granted only to those wishing to be a member of the particular religious order; for example, this automatically eliminated those of an Evangelical faith. Nonetheless, it cannot be underestimated how important this movement was in serving as the foundation for future innovations in nursing. Its chief importance lies in that these orders acted as a forerunner of modern nursing by serving as an example. This movement was also important in that it spread the good reputation of the tra­ditional caring orders among the Evangelical, that is, Lutheran, population. Evangelical orders. In the 1830s the movement to establish Evangelical orders became more active; they modeled themselves on the Catholic orders. The impetus for such a development came from a dissatisfaction with the existing nursing care overseen by the 27 non-Christian civil authorities, which led to the call for a Protes-tant order for young women. While steps in this direction were taken by many individuals, the most well-known and, in the long run, that having the most lasting effects were the efforts of Theodor Fliedner, an Evangelical pastor. Fliedner founded the Evangelical Society for Christian Nursing in 1836. Fliedner's original aim was to prepare nurses to give care to the sick in their homes, in the commun­ity, and--of lesser priority--in hospitals. 28 However, the opposite resulted when it was found that proper care could not be given in the homes of those of the lower industrial classes. The year 1836 is regarded as a milestone in the road toward the secularization of German nursing: Fliedner introduced a balanced curriculum to nursing which incorporated both theory and practice. He saw nursing being able to meet the growing needs of an advancing me dl· ca 1 SC.l ence. 29 Fliedner based his society on the Sisters of Mercy and studied the rules and principles of other orders as well, selecting those rules and principles which he would apply to his order. Somewhat contrary to original expectations, he conferred the title of deaconess (Diakonisse) on the nurses, giving them an ecclesiastical order. In so doing he was responsible for the initia- tl.o n 0 f th e Mo t he r Ho use sys t em 30.ln Ge rman nursl.n g. Fliedner's instructions were strongly influenced by his own theological beliefs. He advocated a threefold service relationship: serving God, serving the sick, and serving one another. In addition to receiving practical experience and guidance in the hospital, nurses attended evening courses. Fliedner believed that Berufsethos, 28 an attitude of serving and caring, was as important as instruction. Before Fliedner would allow his nurses to work in another hospital, he required the hospital to meet certain conditions for their employ­ment; this was consistent with his belief that there needed to be a certain spirit in the whole institution and that nursing could not be isolated from other aspects of the hospital IS functioning. 31 The significance of Fliednerls achievement was that he was able to base Oiakonie care on what was to be a firm and lasting foundation. He established the first organized community in the Evangelical realm and incorporated instruction as an integral part of nursing education. Fliedner also paved the way for the inclusion of a strong Christian ethic in nursing care and education which would last into the twentieth century. Nursing spread rapidly through the Oiakonie: at its twenty-five year celebration in 1861 there were twenty-eight Mother Houses with 1,207 Oiakonissen. 32 Wars and the Growth of Nursing As in the case of many other countries, a further important catalyst of change in Germany was the prevalence of war in the nine­teenth century. The wars that resulted in a freeing of the German kingdoms from the hegemony of Napoleon in the early part of the century also resulted in a new freedom from other rigid structures of life of the eighteenth century. As a response to the appeal of the Prussian princesses to German women to support the war effort in April 1813, women from all classes moved out of the domain of the home into the public realm to give support in any way they could. 33 Even though the 29 groups (vaterlandische Frauenvereine) were disbanded after the war, the experience of women working outside the home and in the public was not forgotten. The idealism of the women's movement would appear again, although with more political overtones, after the 1848 Revolution. Two important developments for nursing in the nineteenth century occurred outside of Germany, but also in relationship to wars; these were the Nightingale nursing movement in England and the found­ing of the Red Cross in the latter part of the nineteenth century by Henri Dunant. The Nightingale movement. Two widely differing systems of nursing, the German Mother House and the Nightingale Nursing Schools, have had a significant influence on nursing education in Western civilization. When "traced to their roots, one comes to the signifi­cant point where Florence Nightingale met Kaiserwerth." 34 Nightingale's influence in Germany, however, was felt less in the realm of the structure of the nursing education35 than in the con­ceptualization of the nursing discipline itself. Her efforts to elevate nursing to the status of a learned profession and her demand for the recognition of nursing as an art were important initiatives for nursing in Germany. Up to the nineteenth century nursing in Germany was looked upon as a gift of talent for which no education was needed. Nightingale's influence furthered nursing as an employment opportunity (freiberufliche Tatigkeit) which at the beginning of the twentieth century was still viewed by the German public and in the press as disreputable. 36 30 The Red Cross. The development of the Red Cross in Germany has had far-reaching effects on nursing and nursing education in that country into the twentieth century. Its development in Germany was different from that in any other country. The purposes of the newly­founded Red Cross were, in peacetime, to concern itself with the education of health personnel and to maintain readiness of emergency health means. Peculiar to the development and spread of the Red Cross in Germany was its adoption of the Mother House system of the Catholic and Evangelical orders. This was an example, as with many of the developing associations in Germany at that time, of the utilization of the organization of the old religious communities and wartime structures. The image of obedience combined well with a particular image of the place of the woman in German society at that time. The existence of wartime hospitals initiated discussion about the institution of the hospital and the need for qualified personnel to work in them. In peacetime, the discussion shifted to the role of hospitals in the health care of the public. It brought to light the need for sufficient numbers of qualified personnel in this area as well. 37 The Women's Movement The search for professional status. In the second half of the nineteenth century the question of the place of women in German society was increasingly raised and with it that of professional employment in nursing (freiberufliche Tatigkeit in der Krankenpflege). In these issues one discovers the roots of the development of nursing 31 as an interconfessional women's profession which was accorded public respect and financial reimbursement. The new professional nurses had free choice of where to work, and they received an educational preparation regulated by law. The sociopolitical tendencies of the times, the "secular" nursing movement, and the women's movement together promoted this development. In the course of the nineteenth century the relationship of women to the family and home changed. Women of the lower class had to work since the husband's income was not sufficient to meet the family's needs. Most often these women worked in the factories under poor conditions, low pay, long hours, and with no work insurance or pension. In addition, they still had to fulfill family responsibili­ties. In well-situated middle-class families the situation differed somewhat. Industrialization freed women from previous time-consuming activities, and they were not satisfied to stay home and busy them­selves there. The result was a group of women who were looking for employment outside of the home. However, with the exception of the role of governess, there was little for a woman of these classes to do that was socially acceptable. 38 The women's movement of the nineteenth century began to chip away at some of these traditional attitudes and open opportunities for employment for middle-class women. Even so it was a slow process. At the turn of the century nursing was still only acceptable if one was a member of a religious order or Mother House. It is interesting to note that those entering the orders were generally from the middle and upper classes. Lower-class girls, widows, divorced women, and the handicapped were not welcome. The family had to help support the young woman in training with money for food. 39 32 It was the usual practice that nurses were assigned their place in the hospital by the physicians. To the growing emancipatory impulses of these times was a "counter-emancipatory" movement which based its arguments on the "natural role of women." This led to a confrontation of the sexes, since nursing was predominantly female and medicine predominantly male. Consequently a gap developed between medicine and nursing as each attempted to define its area of practice. Free nurses. By the turn of the century there were fairly large numbers of individuals working in nursing who were not members of one of the orders or Mother Houses. These nurses were referred to as "wild sisters" or "free sisters,,40 by the other nurses and were held in low esteem by the public as well. The "free nurses" were to be found mostly in the large cities and sometimes formed their own associations. One of the most well-known was Agnes Karll (1868- 1927) who received her education at the Clementinenhaus Hannover, one of the best of the Red Cross schools of nursing, and who later left the Mother House to give private nursing care. She is known as the "Reformer of German Nursing" and was responsible for the founding of the Berufsorganisation Krankenpflegerinnen Deutschlands (the German Nurses Association) in 1903. 41 This group was concerned with promot-ing nursing as a free occupation and achieving three-year, state-regulated nursing education, a central work assignment bureau, and state guaranteed working rights, including an eleven-hour workday. Her strenuous efforts in this direction continued into the twentieth 33 century, and she played an active role in attempting to achieve state regulation of nursing, which first occurred in Prussia in 1907. Various attempts were made in the late nineteenth century to establish schools of nursing which were not bound to one of the orders or Mother Houses--that is, in which upon completion one did not owe allegiance to one of those organizations. Professor Friedrich Zimmer (1855-1919) realized that the orders could only educate a limited number of women--that is, those with particular religious inc1ina­tions-- and that these numbers would be insufficient to meet the needs of society. He founded a school of nursing in 1894 which would advance the freiberufliche Krankenpflege. 42 The Influence of Medicine Medicine did not playa very active role in these various changes, but doctors did wish to circumscribe the realm and place of nursing within the medical field. Rather than Christian charity, they saw it more as a public welfare activity. In 1869 Rudolf Virchow recommended that all state and city hospitals establish their own schools of nursing. 43 Physicians increasingly felt that nurses needed better education to carry out their orders; only then could the success of new healing methods be insured. Further, Virchow viewed nursing as a natural role of women and not men. The Influence of Social Legislation A further important factor of the nineteenth century that would have significant effects on nursing and medicine was the worker 34 legislation passed by the Reichstag during the Bismarckian era: hos-pital insurance in 1883; accident insurance in 1884; infirmity and old age insurance in 1889. 44 This resulted in an increased demand for medical and hospital care; the number of hospitals rose from 1,502 in 1876, to 2,040 in 1885, and to 3,900 in 1900. 45 It meant that workers with minimal income could demand and receive medical care. Medical treatment in all areas increased and requirements for better educated personnel also rose. Thus, women looking for employment out­side of the home found a steady demand for nursing services. Summary The nineteenth century saw nursing decisively proclaimed as a women's Beruf. 46 Anna Sticker sees nursing since the turn of the nineteenth century as falling into three major divisions: 1800- 1850, the time in which modern nursing had its roots in Diakonie nursing; 1850-1900, a time of a great surge in the various religious orders, Mother Houses, and German Red Cross; and 1900-1960, the time in which the berufliche nursing won its place through the actions of the German Nurses Association and the trade union. 47 Kruse notes that as women moved out of the home into the mainstream of society, they remained under the domination of the male priests or physicians, who continued to make decisions for and about them. In spite of all the revolutions and upheaval of the times, the task of nursing remained unchanged: the direct care of patients in their total life situations. 35 The Twentieth Century Perhaps one of the best conceptualizations of the situation of German nursing at the turn of the century is contained in Kruse's description of the varied perceptions of the professional identity of the nurse. She said that the diverging views of this identity can be pictured as a triangle contained within a circle. The three vertices of the triangle represent opposing images of nursing: (1) an act of charity towards one's neighbor liMy reward is that I mayll;48 (2) spe­cialized assistance prescribed by the physician, where the nurse is the helper of the physician and the nurse's goal is to be like the physician and to assume medical tasks; and (3) an employment oppor­tunity for women outside the home with the belief that the workers I rights and conditions of employment of other Berufe should apply equally to the realm of nursing. 49 All three views have in common (hence the enclosure of the triangle within a circle) the perception of the sex specific role of the woman as "serving, obedient, always available, and selfless. 1150 In understanding the legislative actions that were taken in the area of nursing education in the twentieth century, and who supported or opposed what view, one gains insight into West German nursing historically and as it exists today. This is not to say that each of the nursing laws (1907, 1938, 1957, 1965, 1985 pending) will be reviewed in depth; rather, after a general description of the political environment of nursing at the turn of the century, the Federal Nursing Law of 1965 will be used as the basis to describe nursing in the Federal Republic today. Other laws and happenings 36 in the twentieth century will be mentioned when relevant to the issue at hand. The Situation of German Nursing at the Turn of the Century In the early twentieth century, nursing education and nursing practice within the religious communities were inseparable from the ideas and beliefs about service to humanity and one's personal living code. If nursing was not practiced as an extension or fulfillment of one's belief system, sanctions were imposed. 51 The ethical values and beliefs of the communities were absolutized and it was difficult to move nursing away from the view of a charitable calling. 52 Within the orders, the beliefs, values, and norms of the orders held priority over all other goals or ends including pedagogical demands for reform. 53 These early religious organizations did not attempt to collectively influence history or events or solve problems. Their aim was on a more personal basis: to teach the Sister to perform a charitable service for her fellow man as if to God. Consequently little support from these organizations was given to the cause of the women's movement or the efforts to establish nursing as an employment opportunity for women outside the home. This contributed to suspicion about a systematic, differentiated, cognitive, professional prepara-tion for nurses. During this same time, Agnes Karll was working hard within the newly formed German Nurses Association and with members of the women's movement to accomplish these very goals. They were also being pursued by the trade union (Reichssektion Gesundheitswesen) as 37 illustrated in a list of demands published in 1901. 54 By 1928 there were sufficient numbers of nurses (4,238) in the trade union to warrant the formation of their own branch, the forerunner of today's Nursing Division of the Public Workers Union (Gewerkschaft offentliche Dienste, Transport und Verkehr).55 Early Legislation In 1869 there was already legislation concerning employment for several groups of health workers including physicians, pharmacists, and midwives (the Gewerbeordnung). That there were no references to nursing in this regulation caused dissatisfaction on the part of some physicians, politicians, and nurses. They believed it was important to have some sort of proof of competency for nurses. The hospitals were in dire need of personnel and often hired unqualified individuals to give patient care. In 1898, the editor of a nursing publication who was later appointed to the Prussian Ministry of Medicine, expressed the opinion that the state was obligated to direct the education and practice of nursing personnel to protect the sick from inferior and inadequate care. 56 It is revealing to note that the aim at this time was not to amend the Gewerbeordnung to include nursing, but to draw up a different, special legislation to deal with it. This was because the Gewerbeordnung dealt with employment and nursing was not viewed as such. 57 Opposing this were the orders, who wanted to be left out of any legislation that might be formulated-­that is, not only not to participate in its formulation, but also to have it not apply to them and their schools. 38 This was the situation at the turn of the century as the struggle for state regulation of nursing was begun, a move welcomed in some quarters and rejected in others. Those who supported such a move included some physicians and politicians and a relatively small group of nurses. 58 Against it were some of the most influential associations and conservative politicians. The physicians wanted better educated and more comprehensively educated nurses whose abili-ties were more in line with the recent medical advances. The politi­cians wanted better working conditions for the nurses and the require-ment that the hospitals would only hire qualified nurses. They argued that these better conditions could only be demanded if the personnel were better educated. At the same time, the higher level of qualification would then prevent them from being replaced with less well-educated persons, whose care endangered patients. Those in nursing who supported the need for legislation did so for these reasons and because nursing offered an employment opportunity for women with the possibility of a professional education. With such a regu­lated, specialized education the field of nursing would be more clearly delineated, and the status and self-confidence of nurses would rise. Consequently nurses would be able to represent their own interests and concerns in the hospitals and public realm. Those opposed to government regulation of nursing argued as follows: (1) nursing is primarily a charitable act, and the learning of technical skills and theoretical knowledge should not be over­emphasized; (2) a test had minimal benefit since important ethical and moral qualities could not be tested; (3) a generalized regulation 39 of nursing education would limit the scope of charity work (caritative Arbeit); and (4) such an increase in knowledge brought with it the danger of quackery.59 The first law regulating nursing was passed in Prussia on 1 June 1907, requiring an oral and practical examination after one year of education. Theoretical and clinical hours were not prescribed, Netz emphasizes that the state regulation of nursing education resulted not because of an increased amount of knowledge in nursing, but because of the uncertain situation of the freiberufliche nurses. In order for them to avoid becoming a nursing proletariat, they needed state regu- 1atl·o n 0 f th e e du ca t'lo n an d wor k con d1' t'l ons. 60 It was stated earlier that while several health professions were already to some degree regulated by government legislation, nursing was not. Part of the reason for this was due to the fact that nursing often occurred within "closed institutions," that is, in hospitals run by the religious orders. As a result, work conditions and abuses remained hidden from the public view. The activities of the nurses also seemed very diffuse: nursing often contracted for the entire operation of the hospital,6l so that it was difficult to specify what nursing was. As long as nursing was described as an attitude or calling, nursing education remained an emotional issue, not a rational one. 62 Problems with Reform in the Twentieth Century Over the century the resulting legislation has been a compro-mise of opposing views about the understanding of nursing, as held by various segments of the nursing community, the hospitals, the 40 physicians, and the politicians in whom much power resides. Nurses are not members of the Ministry of Health at Land or federal levels; government employees who fill these positions must have a university education. Nurses rarely have shown consensus on the need for changes. In addition, legislators and health officials have had their own con-cerns for reforms. The consistent presence of a shortage of hospital nursing personnel has led to a distinct fear that higher standards for admission to schools of nursing would intensify the shortage. These arguments were repeatedly voiced in discussions of the 1957 and 1965 laws. 63 Concerns often centered on making nursing attractive to young people as a Beruf. These concerns resulted in tariff agreements being adopted in 1967 which established payments for students that were uni­form throughout the country. In discussing the influence exercised by the various nursing organizations in West Germany, a few words about World War II will shed some more light on the situation. When the National Socialists came into power in 1933, they banned the freiberufliche nursing organizations (including the forerunner of the German Nurses Associa­tion) and formed their own National Socialist organization for workers (Deutsche Arbeitsfront).64 During this same time, the religious orders and Mother Houses had been able to retain much of their own autonomy within their hospitals. Hence, at the end of the war, while many nurses were under the suspicion of being Nazi "brown nurses,"65 the religious organizations were unblemished, with their mechanisms of power and structure still in place. On the other hand, the freiberufliche nurses were sometimes released from employment and 41 replaced with Mother House nurses. 66 They and their prewar nursing organizations had to start anew in organizing structures, building schools of nursing, and so forth. M. Elaine Wittman indicates that there were as many as sixty­six nursing organizations in the FRG in 1967. 67 These organizations fall into one of three categories: the trade unions, the professional nurses' associations, and the confessional (religious) and Red Cross Mother House organizations. Today the latter work cooperatively under the umbrella organization of the German Union of Nurses Organiza-tions (ADS). It would be erroneous, however, to suppose that these groups always concur in their views, or that alliances do not shift among the various groups depending upon the issue under discussion. Edith Fischer, in a review of the development of German nursing in the twentieth century, stated that the road for the professional (freiberufliche) nurse in Germany was much more difficult than in many other countries, due to the strong influence of the Mother Houses. However, she sees these diverging views of nursing as a strength rather than as something negative. While all organizations agree on the basic premise or task of nursing--that is, to help the ill person--there is a multiplicity of views about most other issues. They allow richness of opportunity and many possibilities for those enterl.n g nursl.n g. 68 Consideration of the hypotheses which were confirmed in Kruse's dissertation using an historical methodology will further illustrate the development of German nursing education in the twen-tieth century: 42 1. The beginning of modern nursing in confessional women's communities, that were predominantly founded and led by men, has contributed in a considerable measure to nursing being socially accepted for a long time as a serving activity of women without income. 2. The religious orders [Schwesterngemeinschaften] are not to be equated with professional associations. Professional associations represent the interests of the members of the profession. The Orders place primary emphasis on the religious goals of the Order and place the professional interests of its members second to this. Professional qualification is accorded meaning insofar as it appears necessary for the fulfillment of the spiritually motivated demands. 3. The structure and organization of the profession as self-determined by the members of the profession, an important characteristic of professionalization, has only been able to be accomplished in beginning steps to the present time. 4. The relatively high measure of outside determination of the profession has led to instances of outside determination of the structure and organization of the education. S. As a result of the foregoing, the control of the education, which in a great measure is made possible through the control of the state examination, has not come within the responsibility of the members of the professional group.69 Through her discussion and substantiation of these hypotheses, Kruse demonstrates the significant impact that the traditional church organizations, closely bound with the concept of serving, have had and continue to have on West German nursing in the twentieth century. She distinguishes between the perspective towards nursing of these more traditional groups and those interested in a professionalization of nursing, and demonstrates the hindrance that outside control of nurs­ing has had on the development of nursing education. She demonstrates how the historical traditions and structures of nursing have resulted in a continued lack of self-determination of nurses for their own profession and educational system. 43 The Nursing Law The law currently in effect in West Germany (dated 1965) and subsequent amendments will be outlined in this section, and its provi­sions will be used as the basis for describing the present education system. 70 The Federal Nursing Law (Krankenpflegegesetz) controls and regulates nursing licensure and the basic nursing education system in West Germany. The law authorizes two levels of nursing, a nurse assistant (Krankenpflegehelfer or Krankenpflegehelferin), who is edu­cated in a one-year program, and the counterpart of the American registered nurse, the Krankenschwester or Krankenpfleger,7l who is educated in a three-year program. Each must pass a state licensing examination at the completion of the educational program. The nursing license allows the use of the title of "nurse," but it does not define the practice of nursing. While the law controls the basic nursing education, it does not regulate postbasic education or continuing education. The control of the postbasic education is at the discretion of the Lander, and at present few exercise their authority in this area. The Federal Nursing Law and nursing regulations serve as a framework after which the Lander model their own regulations, thereby implementing and enforcing the federal law. The control of nursing education at the Lander level is usually handled through the Ministry of Work, Health, and Social Affairs. 72 In 1892 there were 814 schools of nursing with 52,941 study places, which means the average school had sixty-five students. 73 The schools of nursing must be authorized by the relevant department of the Ministry of Health in the 44 respective Land in which they are located. The schools of nursing are not under the jurisdiction of the education ministry as the rest of the education system is. Nursing is a IIspecial education system ll in a category of its own; neither is it included in the law regulating apprentice education. It is clearly outside of the general education system, a point of much discussion and controversy.74 While the schools of nursing must receive authorization to open, they are not reaccredited at periodic intervals. Rather control is maintained through the examination at the end of the students' education. A nursing school must be affiliated with a hospital which has a specified minimal number of specialty departments. Until the 1957 law, only physicians could act as directors of the schools. The majority of schools today are led by a combination physician-nurse director team. Little is said in the law in reference to the faculty. The law states only that an adequate number of nurse instructors must be available and at least one must have completed the postbasic education for instructor of nursing. There are no fixed ratios of faculty to students, or the number of students to a hospital, or the number and/or size of classrooms and facilities needed for the school. The students receive instruction from at least four different groups of people: (1) physicians, who generally teach about illness, disease, and pathology; (2) nurse instructors, who teach the theory portion, that is, nursing care of patients with various disorders; (3) lec­turers in associated fields (Dozenten), who teach nutrition, sociology, psychology, anatomy, and so forth; and (4) hospital staff nurses, 45 who supervise and teach students on the clinical units as their time and experience permit. The length of training is required to be three years. How-ever, there are exceptions to this requirement. For example, a pedia-t rlC. nurse 75 s t ud Y·ln g t 0 be a II genera 111 nurse s t ud ·l es f or a sho rter time and vice versa. More specific regulations concerning the educa-tion and state examination, such as those regarding curriculum hours and clinical practice hours, are specified in the Nursing Education and Examination Regulations,76 which are not part of the law but a separate set of regulations issued by the federal Ministry of Health. This specifies a requirement of a minimum of 1,200 theoretical hours. The minimal number of weeks of training in the various hospital specialties varies; for example, twenty-six weeks are needed on a medical ward, thirteen weeks on a surgical ward, and so forth. The current draft of the new nursing law, which has been under discussion for more than ten years, requires a minimum of 1,600 hours of theory courses. This would bring West Germanyls standard into line with that of other Common Market countries and facilitate mobility of nurses among the various countries. 77 The state examination occurs at the conclusion of the educa-tional program and consists of written, oral, and practical portions. The oral and practical portions were implemented in the first law in 1907; the written portion was added in 1965 in an effort to add to the objectivity of the examination. If the examination is passed, the individual receives a permit to practice nursing which is valid for life and in every Land. The state examination is administered by 46 an Examination Committee, which is chaired by a representative of the regional health authority (a physician) and which has four other mem­bers. Two of these are physicians and two are nurses, one of which is the director of the school and another who must be a representa­tive of the teaching body of the school. The exact procedures of the examination are not laid down at the federal level, and there is some variation in these among the Lander, though in principle the examination is supposed to be the same in all Lander. The two-day practical portion, about which the student submits a written report, is administered by nurses; this bears little weight in the overall grade. The written report may then be graded by a physician who did not supervise the practical experience; this practice often results in an illness-oriented, rather than a patient-oriented, report. 78 The written examination (not to be confused with the above-mentioned written report about the practical experience) may include questions about nursing or the associated subject areas. The oral portion is generally administered by physicians over the various illnesses, their pathology and treatment, and background science subjects. This is the most heavily weighted part of the examination;79 a student may do poorly on the nursing practical portion but pass the overall examination because of high achievement on the oral section. 80 Funds for the schools of nursing come from the daily hospital rate paid by the patients or, more likely, from federal health insur­ance monies; generally there is not a separate budget managed by the director of the school of nursing. The status of the students is specifically addressed in the federal law. Students have tariff 47 agreements which are negotiated by the trade union. A written con­tract must be given to the student at the beginning of training. Monthly payments are received by the students. The students are in­sured against illness, accident, and infirmity, and the time spent in the education counts toward retirement. The status of students closely resembles that of employees in the hospital setting. Three to four students usually replace one nurse in the hospital scheduling plan. Since the hospital bears the expense of students, there is normally little or no community nursing experience. 81 The minimal entry requirements for age and education level are also specified in the law. Students must be at least seventeen years old and must have completed ten years of schooling. Nursing in the FRG Today Employment. The majority of graduate nurses in the FRG-­over 80 percent--work in hospitals that are operated by the state, operated by the church, or in a few cases, privately run. The second largest group is employed in community health nursing; very few nurses are employed in industrial nursing. In 1980 there were 192,727 nurses in the FRG--162,756 female and 29,977 male. There were also 25,437 female pediatric nurses and thirty-three male pediatric nurses, which when added to the previous figures yields 218,164 nurses with a 13.7 percent male population. 82 Several of the nurses interviewed maintain that the percent of male nurses is dispropor­tionately higher in administrative positions, but figures are not available to confirm or disprove such a thesis. 83 48 Postbasic nursing education. Both the postbasic nursing education and continuing education offerings fall outside the responsi­bility of the federal government and are under the jurisdiction of the Lander. Specialization in nursing occurs in the postbasic nursing programs in such areas as intensive care, operating room, psychiatric, and community health nursing, and for such positions as unit head nurse, director of nursing service, and instructor of nursing. These programs vary in length from several months to two years. There is some consistency in the program length of the specific areas--for example, most of the instructor courses last from eighteen months to two years, while the head nurse courses tend to be considerably shorter, often three months in length. The cost of these programs is borne by the students with some financial assistance coming from institutions such as the Federal Board of Labor. The programs are offered by various organizations, such as the trade union, the German Nurses Association, the Diakonie, and the Red Cross Mother House. The Berlin Ministry of Health sponsors a program as do an increasing, though still very small, number of universities--for example, Heidel­berg and OsnabrUck. These latter are at the university and not of the university. Continuing education. Continuing education is not mandatory. Programs are often offered by the hospitals as well as by the above­mentioned organizations. They vary considerably in length and con­tent, covering many topics ranging from psychoanalytical family therapy and creative teaching strategies to legal issues in nursing and care of the terminally ill. Nursing process is often the focus of 49 continuing education courses and while commonly found in the post­basic nursing courses, it is still somewhat new to the basic nursing education programs. It is within the last five to ten years that nursing process entered West Germany and it is seen as an important means of documenting nursing's contribution to health care. It is still possible to visit hospitals in which there are no nurses' notes and no legal documentation of what nurses do. On the other hand, there are hospitals in which care plans are used on all patients admitted to a unit. Nursing research. Nursing research is also a new theme for West German nurses. A working conference was held in February 1984 to discuss such issues as the need for nursing research, the priorities for research in the Federal Republic, the proper professionals to conduct it, and so forth. 84 International health organizations play an influential role in shaping West Germany's ideas and directions in nursing. These include, to name a few, the World Health Organization, the International Council of Nurses, and the Workgroup of European Nurse Researchers, who formulate guidelines for member nations. Assignment and salaries of nurses. In the hospitals one most commonly finds the functional method of assigning nurses to patient care. However, it is becoming increasingly frequent to also encounter Zimmerpflege (room care), a system in which one nurse cares for a group of patients in one or several rooms for the duration of the shift. Salaries correspond to responsibilities or areas of employment as specified in the salary schedule (Sundesangestelltentarif). For example, the director of a school of nursing with 180 students is paid 50 more than the director of a school with eighty students. A nurse working in a dialysis center with at least four machines earns more than a nurse who applies casts in a castroom. 85 The trade union and employers negotiate salaries at a national level; hence there are no regional differences in salaries. West German health care system. While the reader who is interested in a more detailed knowledge of the West German health care system in general is encouraged to seek additional resources in this area,86 it is helpful to know that West Germany has a national health insurance plan, which pays the health care costs of 93 percent of its population. 8? The Federal Republic does not have "socialized medi-cine," a term often used by Americans in referring to the system. Patients choose their doctor, and not all health employees are state employees. In West Germany the physician is highly respected and viewed as the individual competent to make decisions about health affairs and health planning. Nurses participate in decisions pertaining directly to nursing or nursing education and then only in an advisory role. Nurses are not in the positions, political or administrative, to make the final decisions about nursing affairs. As almost all nurses interviewed brought up consistently, nurses are not in the positions of power and influence in the federal or Land governments. They participate in advisory capacities when, for example, regulations on nursing are to be discussed. Nurses are not represented in Land positions through which the regulations themselves are enacted; hence, the chair of the Examination Committee for the nursing state 51 examination is a physician. Problems and issues in West German nursing. Further insight into the West German nursing and nursing education system may be ob­tained by knowing what they consider to be some of the problems of their system. Prior to beginning the actual dissertation research, the researcher spent nine months in the country in 1981 and 1982 interviewing German nurses and visiting hospitals and schools of nursing to learn about the structure and organization of their system. One question asked of all persons interviewed, whether nursing school directors, instructors, staff nurses, or representatives of a partic­ular nursing organization, was what they perceived to be the problems facing West German nursing and/or nursing education at that time (most of the interviews were conducted in the winter of 1983). The nursing literature was also reviewed and cited problems were extracted from there as well (see Appendix B for a list of sources). The responses are divided into three areas: nursing education, nursing service and practice, and the role of the nurse. These are not clear-cut categories, and one response could sometimes be classified in anyone of the three. Concerns expressed about nursing education include the issue of whether the nursing student is an apprentice or a student, the contradiction of students· learning by unit nurses, the difficulty of applying classroom teaching to the clinical setting, the non­specification of uniform curricular objectives throughout the Federal Republic, the need for more classroom teaching hours than the present minimum (1,200 hours), the shortage of qualified instructors, 52 the lack of clinical supervision of the students, and a socialization of the students which sets them up for later dissatisfaction with the profession. For example, students are overloaded, perform tasks for which they have not been educated, and give medications without proper supervision. Problems identified that might be categorized under nursing practice include the lack of partnership of nursing and medicine, shorter work times leading to nurses not knowing patients as well and increasing the need for better documentation, shorter patient hospital stays increasing the load on the nursing staff because the patients that are there need more intensive care, a focus on the disease entity rather than the patient, and a fascination with the technical aspects of nursing which overshadows its psychosocial aspects. Issues that deal with the nursing role and professionaliza­tion include the indefinite role of the nurse; the indistinct boundaries between nursing and medicine; much dissatisfaction among nurses due to the personnel situation, salary, shiftwork, hours, and lack of childcare facilities; too much specialization in nursing resulting in a fragmented view of the patient; the lack of autonomy of the nurse; and the concern that the nursing law does not reflect what is important and is outdated before it is implemented. The nurses believe these issues have a negative impact on the nursing profession in several ways: the average stay in nursing is about four years, the nurse ;s unsure of her professional identity and has a lack of self-confidence, and, due to their lack of 53 autonomy, nurses cannot practice nursing as they have been taught in their education. 54 Notes lArthur Hearndon, Education in the Two Germanies (Oxford: Western Printing Services, 1974), p. 29. 2The Constitution of 1949 establishes West Germany as a federation of states (Lander, singular: Land); the country is made up of ten Lander, two of which are city-states, and West Berlin. Often (and for the purposes of this paper) West Berlin is considered the eleventh Land. 3Vernon Mallinson, An Introduction to the Study of Compara­tive Education, 4th ed. (London: Heinemann Educational Books, 1975), p. 184. 4In some Lander, especially the three city-states, there are deviations from this basic pattern. 5See Appendix C for German titles of these various councils. 6Mallinson, Comparative Education, p. 185. 7GUnther Kloss, West Germany: An Introduction (London: MacMillan Press, 1976), pp. 116-117. 8Mallinson, Comparative Education, p. 215. 9Walter Hahn, "Upward Academic Mobility for the Nonsecondary School Graduate: Some Avenues Open to Young Adults in West Germany," Higher Education 9 (January 1980):11-16. 10Mallinson, Comparative Education, p. 251. llDaniel Fallon, The German University (Boulder, CO: Colorado Associated University Press, 1980), p. 55. 12 Ibid ., p. 57. l3 Ibid ., p. 58. l4John Van de Graaf et al., Academic Power: Patterns of Authority in Seven National Systems of Hi her Education {New Yo~k: Praeger Pub ishers 978, pp. 27-28. 15Walter Hahn, "Extending Equal Opportunity in West German Higher Education," Educational Record 58 (Fall 1977):405. 16 Ibid ., p. 409. 17 Ibid . 55 18While the topic of this paper deals with the nursing educa­tion system in the FRG, the more general term "Germany" will of necessity be used in this chapter, at least in its earlier sections, since the country known as the Federal Republic did not exist until after 1949. Any discussion of pre-World War II events therefore refers to the nation-state of Germany, an entity whose boundaries have repeatedly changed over time. 19It is understood that it is impossible to render a totally "other" account of something unless one used only quotations, which even then have been selectively chosen. This paper is also affected by biases that may be inherent in the researcher's translation of various sources. 20Eduard Seidler, Geschichte der Pflege des kranken Menschen, 5th ed. (Stuttgart: Verlag W. Kohlhammer, 1966), p. 134. 21 Ibid . 22Anna Sticker, Die Entstehun der neuzeitlichen Kranken fle e (Stuttgart: Verlag W. Kohl hammer, 1960 , p. 13. 23Anna-Paula Kruse, "Die Entwicklung der Krankenpflegeaus­bildung seit der Mitte des 19. Jahrhundert" (Ph.D. dissertation, University of Osnabruck, 1983), p. 2. 24Freiberufliche Krankenpflege denotes the practice of nurs­ing as any other profession/occupation with similar societal recogni­tion, economic security, and individual choice as opposed to the control of nurses and nursing practice through organizational struc­tures such as orders, Mother Houses, or the Diakonie. 25Sticker, Entstehung der Krankenpflege, p. 114. 26Seidler, Geschichte der Pflege, p. 146. 27Sticker, Entstehung der Krankenpflege, p. 201. 28 Ibid ., p. 33. 29 Ruth Elster, Nursing in the Federal Republic of Germany (Frankfurt: Deutscher Berufsverband fur Krankenpflege, n.d.), p. 3. 30 llAs regards the practice of the profession, nurses came under the control of the Matron of the Mother House in the same way that the members of the Catholic Orders were responsible to their Superior. They did not work for their own benefit but for the profit of the Mother House and were under its control. In exchange for her work, the Mother House provided the nurse with shelter, food, and clothing, and it was their home for the rest of their life, receiving care in sickness and old age. II Ibid., p. 4. 31Sticker, Entstehung der Krankenpflege, p. 39. 32Seidler, Geschichte der Pflege, p. 151. 33 Ibid . 56 34Florence Nightingale studied nursing at Kaiserwerth under Fliedner from July to October 1851. 35An adaptation of Nightingale's suggestions for the inde­pendence of schools of nursing from hospitals was instituted at the Berliner Victoria-Haus in 1881/82, incorporating at the same time some aspects of the Mother House system; however, these recommendations did not gain a strong footing in Germany. Anna Sticker, Florence Nightingale Curriculum Vitae (Dusseldorf-Kaiserwerth: Diakoniewerk, 1965), p. 8. 36 Edith Fischer, "Deutsche Krankenpflege im 20. Jahrhundert: 1. Entwi ckl ung der deutschen Krankenpfl ege," Deutsche Schwestern­zeitung 9 (August 1956):200. 37Seidler, Geschichte der Pflege, p. 160. 38Kruse, "Entwicklung der Krankenpflegeausbildung," p. 13. 39 Ibid ., p. 37. 40The use of the term "Sisters" (Schwestern) to refer to nurses has been common well into the twentieth century. This term is often used today in the title of the nurse--that is, "Sister Helen"-­even when the nurse is not a member of one of the orders or Mother Houses. 41While I will consistently refer to the professional nurses' organization as the "German Nurses Association," it actually underwent two name changes since its founding in 1903: Berufsorganisation der Krankenpflegerinnen Deutschlands (1903-1938), Agnes Kar11- Verband (1945-1973), and Deutscher Berufsverband fur Krankenpflege (1973-present) . 42Fischer, "Deutsche Krankenpflege: I," p. 200. 43seidler, Geschichte der Krankenpflege, p. 165. 44Kruse, "Entwicklung der Krankenpflegeausbildung," p. 14. 45 Ibid ., p. 16. 46There is no exact translation to English of the German word Beruf. "Profession," "occupational field," "discipline," 57 "job," "career," and "vocation" may all be used from case to case and be accurate. The discussions in nursing in the United States and the cautious use and differentiation made between "profession" and "occupation" are not encountered in the use of the German word Beruf. While it is increasingly common to speak of professionalization-----­tendencies in German nursing, one still does not distinguish between medicine as a Profession and nursing as a Beruf. They are both Berufe (plural). For the purposes of this paper, Beruf and its derivatives (berufsgualifiziert, berufliche, etc.) when translated, will be rendered as "profession," "professional ," etc. 47Sticker, Entstehung der Krankenpflege, p. 9. 48Kruse, "Entwicklung der Krankenpflegeausbildung," p. 22. 49 Ibid . 50 I bid., p. 21. 51 See previous comments on page 32 discussing attitudes to-wards the "wild sisters" and public and press images of them. 52Kruse, "Entwicklung der Krankenpflegeausbildung," p. 98. 53 I bid., p. 1 00. 54 Emil Fritz, "Ein schwerer und weiter Weg," Gesundheitsreport 3/4 (1978):12. 55 Ibid . 56Kruse, "Entwicklung der Krankenpflegeausbildung," p. 103. 57 Ibid . 58 I bid., p. 1 56. 59 Ibid ., p. 158. 60Tilmann Netz, "Entstehung und Entwicklung der Kranken­pflegeausbildung," Die Schwester/Der Pfleger 16 (February 1977): 50. 61 The roots of Mother House contracts go back to 1639 when Madame LeGras, who worked closely with Vincenz von Paul in France, signed the first contract between the Sisters of Mercy and a hospital in which the Sisters took over the care and running of the hospital including the filling of doctors' orders; in return they received their lodging and own care. The entire management of the hospital was their responsibility alone; the hospital was responsible to "protect the dignity of the Sisters" which included not criticizing 58 them in front of the patients. Seidler, Geschichte der Pflege, pp. 117-118. 204. 62Netz , "Entstehung der Krankenpflegeausbildung," p. 51. 63Kruse, "Entwi ckl ung der Krankenpfl egeausbi 1 dung," pp. 196- 64 Fritz , "Ein schwerer Weg," p. 13. 65 Ibid . 66 Ibid . 67M. Elaine Wittman, "Nursing Education in West Germany," in Current Perspectives in Nursing Education, Mosby's Current Practice and Perspectives Series, vol. 1, ed. Janet A. Williamson (St. Louis: C. V. Mosby, 1976), p. 175. 68Fischer, "Deutsche Krankenpflege," p. 202. 69Kruse, "Entwicklung der Krankenpflege," p. 32. 70Krankenpflegegesetz vom 20.September 1965 (BGB1. IS. 1568), quoted in Werner Schell, StaatsbUr er- und Gesetzkunde fUr die Krankenpflegeberuf, 5th ed. Stuttgart: Georg Thieme Verlag, 1983), pp. 348-356. 71 In the German language one distinguishes between female and male personnel through the use of different words or endings. Hence a female nurse is a Krankenschwester; a male nurse, a Krankenpfleger. A female nurse assistant is a Krankenpflegehelferin; a male nurse assistant, a Krankenpflegehelfer. 72The exact name of this Ministry may vary among the Lander. 73Deutsches Krankenhaus AdreSbuch, 20th ed. (Freiburg: Verlag Rombach, 1984), p. 223. 74While there are numerous writings in the German literature on the subject, Anna-Paula Kruse discusses the many facets of the issue in considerable depth in her 1978 Diplomarbeit, "Die Krankenpflegeausbildung in ihrer unklaren Stellung zwischen dualer Ausbildung und Berufsschulausbildung und die Bestrebungen um eine Integration in das Bildungssystem (Sekundarstufe 11)," which was published in the Deutsche Krankenpflegezeitschrift 31 (Setpember­December 1978). 75pediatric nurses are educated in separate three-year nursing education programs from "general" nurses. 76AUsbildungs- und PrUfungsordnung fUr Krankenschwestern, Kranken fle er und Kinderkrankenschwestern vom 2. August 1966 BGB1. IS. 462 , quoted in Werner Schell, StaatsbUrger- und Gesetzkunde fUr die Krankenpflegeberuf, 5th ed. (Stuttgart: Georg Thieme Verlag, 1983), pp. 357-363. 59 77It should be emphasized that the nursing law and regulations establish the minimum standards for schools; it is often the case that the schools increase their hours over these on their own initiative. 78Kruse, "Entwicklung der Krankenpflegeausbildung," p. 226. 79 Ibid., p. 227. 80Ibid ., pp. 227-228. 81There was an effort to have this included as a mandatory part of the curriculum in the 1985 draft of the nursing law. 8211Statistik Uber die berufstatigen Krankenpflegepersonen," Deutsche Krankenpflegezeitschrift 35 (October 1982):634. 83The issue of the availiability of current statistics on women in the work force surfaced in several interviews as well as in a seminar, "Problems of Working Women," which the researcher attended at the University of Kiel during the summer semester of 1984. The two most common interpretations of the meaning assigned to this deficit included a lack of interest on the part of the government in problems which women in the work force encounter, despite verbalisms of the opposite stance, and the governmentls fear that women might suggest changes or reforms based on any numbers it might make available. 84This was the Arbeitsta un Kranken fle eforschun [Work Conference on Nursing Research held at the Bildungszentrum Essen des DBfK from 16-19 February 1984. 85Gewerkschaft oTV, Ausbildun in der Kranken fle e: Gesetzliche und tarifliche Bestimmungen Mainz: n.d.), pp. 55,60. 86Two of the many possibilities would be Siegfried Eichhorn, "Health Services in the Federal Republic of Germany," in Marshall Raffel IS Comparative Health Systems (University Park, Pennsylvania: Pennsylvania State University Press, 1984, pp. 286-334; and J.­Matthias Graf Schulenburg, "Report from Germany: Current Conditions and Controversies in the Health Care System," Journal of Health Politics, Policy and Law 8 (Summer 1983):320-351. 87Eichhorn, "Health Services," p. 311. CHAPTER II BIRTH: CONCEPTUALIZATION OF THE MODELLVERSUCH The purpose of this chapter is to present the course of events leading to the implementation of the IIModellversuch: Development and Testing of a Three-year Course of Study for Instructors in the Health Professions" at the Free University of Berlin (FUB). The following two chapters expand on this with an overview of the aims of the program and its actual implementation (Chapter III) and a review of the efforts that were made to secure its future as a permanent course of study at the Free University (Chapter IV). The funding for the experimental program was provided by the Federal-States-Commission for Educational Planning beginning on 1 October 1976. The Final Report is dated 30 June 1982. The information for this presentation came from several sources. Seven individuals involved in the planning, leadership, and teaching of the Modellversuch, and two individuals each in the health and education ministries, were interviewed. Another major source is the seven reports of the Modellversuch, which include minutes of university committee meetings, numerous articles written about the program, and letters exchanged between key individuals in the university and government ministries. l Various other books, articles, and interviews with individuals not directly involved with the Modellversuch were employed as appropriate. Important information 61 was also gleaned from the master's thesis of a research assistant of the Modellversuch, which provided documentation of the events lead-ing to the conceptualization of a university course of study in nursing in the FRG. 2 Necessary to the full understanding of any event is the placement of that event within its historical, political, and socio-economic context. This is the aim of hermeneutics and is the method of data analysis used in this paper. At the same time it is important to bear in mind that historical processes are dialectic in nature. Change, reform, and movement do not occur in smooth linear transitions, nor without conflicting, opposing forces coming into play. It is the dominance of one of these contradictory opposing forces that eventual-ly results in one innovation taking precedence over another. There-fore, it is important to make explicit the contradictions that are present in situations and not minimize differences and conflicting perceptions. Because of the dialectical nature of history, this paper begins with a discussion of the conceptualization, the birth, of the Modellversuch, whose noncontinuation, or death, is of primary interest. Death has no existence and no meaning without birth; so too the end of the Modellversuch is not understandable if the roots of its creation are not understood. Conceptualization of Three-year University Courses for the Health Professions Recommendations of the 1973 Wissenschaftsrat In written reports and discussions with individuals familiar with the circumstances leading to the development of the Modellversuch 62 at the Free University of Berlin in the mid-1970s, the "Recommenda­tions of the Wissenschaftsrat for Modellversuche" (1973)3 was consistently referred to as the most important catalyst in preparing the way for such an innovation. The content of the recommendations was released at a press conference on 9 July 1973; the recommendations concerned reforms in three of the many health professions existing at that time: biomedical technology, laboratory technology, and nurs­ing. Included in the paper were the reasons for considering changes in these fields, descriptions of the performance areas of the graduates of the proposed programs, and educational goals of the programs. The recommendations pertained to basic education courses of study in these fields rather than postbasic or continuing education offerings. Perhaps the most controversial point contained in the recommendations were the proposed titles of the graduates of these new programs, which created visions of an abbreviated course of study for physicians and correspondingly inadequately prepared practitioners.4 Background of the Recommendations of the Wissenschaftsrat At a full session of the Wissenschaftsrat on 23 July 1971 the decision was made to establish a "Task Force for Health Education. 115 Its charge was to examine the recommendations of educational reformers calling for three-year, six-semester, university courses of study for their applicability to the health care profes­sions. 6 The task force included members not only of the Wissenschaftsrat, but also of the Medical Committee of the Wissenschaftsrat, as well as nonmember experts, including nurses and 63 members of the other nonmedical health professions. The task force met for the first time on 21 October 1971. Over the next seventeen months the committee met eight times. In March 1973 it presented a draft of recommendations for review to the Medical Committee of the Wissenschaftsrat. In light of this group's comments, the final draft was presented to the full session of the Wissenschaftsrat for its approval on 11 May 1973, and released to the public at the press con-ference in July 1973. Before discussing the responses of various groups to these recommendations and the subsequent course of events leading to the development of the Modellversuch at the Free University of Berlin, the events leading to the formulation of the recommendations of the Wissenschaftsrat will be reviewed and the reasons examined why this body of scholars was interested in a shortened course of study at the university, and why in particular for the health professions. Education Policy Developments in the 1960s and 1970s The 1960s were a time of worldwide unrest at universities. West Germany's campuses were no exception. 7 Much discussion and dialogue went on during and following this time within and among the universities, government agencies, and educational circles, some of which resulted in recommendations for educational reforms. Following is a very brief review of a few of these suggested changes.S It is hoped that this will give the reader a sense of the issues that were being raised and the traditions challenged. They are also reviewed to clarify the origin of the Wissenschaftsrat's recommendations, which did not materialize in a vacuum, but rather whose history was laid in 64 a dialectical process of criticism and counter-criticism. liThe Recommendations of the Wissenschaftsrat for the Reform of Study at Universities ll (1966) called for a nonspecific condensing of university courses of study and the division of the study into blocks, such that the majority of students would leave the university after completing the basic study (Studium) and a much smaller per­centage-- perhaps 20 percent--would pursue advanced study (Aufbaustudium). Along a similar vein were liThe Recommendations of the Wissenschaftsrat for the Improvement/Expansion of the University by 1970 11 (1966) which called for study reforms that would result in streamlining education through individual counseling, small group work, increased examinations, limitations on course content and con­tent tested, as well as limits on the number of courses or seminars required for completion. liThe Comprehensive Higher Education Development Plan I - Baden WUrttemberg ll (1967) advocated a shortened course of study (three years) qualifying one for a profession. It recommended calling these II short study courses ll to emphasize the contrast with the usual longer course of study. While the entrance requirements would be similar (the Hochschulreife, or Abitur), the completion degree would be a baccalaureate rather than the Diplom. Not surprisingly, this drew sharp criticism from some parties who pointed to its "functionalistic tendencies. II Stephan Leibfried emphatically opposed the distinction of short and long studies and the division of research-oriented versus professional education. The Weizsacker Plan (1970) proposed that knowledge 65 (Wissenschaft),9 research, and practice can indeed be unified in a shortened course of study; the key was the structuring of the content. Through the analysis of relevant social problems, student motivation and performance would increase, and specific content areas could be taught in reference to these problems. Also appearing in 1970 were liThe Recommendations of the Wissenschaftsrat for the Structure and Improvement of Higher Education after 1970." These recommedations emphasized the division of study into blocks mentioned in the 1966 proposals and the aim to educate individuals for subsequent profes­sional employment but not for a specific profession. It was also in this paper that the suggestion was made to bring the healing profes­sions into the higher education system (tertiar Bereich). Another significant publication in this line of dialogue and criticism was the "Draft of the Federal Government for a Framework Law for Higher Education" which appeared in September 1973. This draft distanced the newly revised educational policy from Humboldt's model of university education--education for a small elite and research free from all social interests--claiming this model was not suitable for a highly industrialized society. It advocated making the preparation for professional work more accessible to all classes of society and proposed that, while there should be freedom in research, that research should be related to society's interests and needs in some way. It encouraged the development of experimental models to this end. In general, the various recommendations and "counter­recommendations" encouraged reform models that joined knowledge and practice. They sought to establish mobility between the practice field and the ivory tower, the world of studies. Desire for Reform Emerging Out of the Health Care Field 66 The previous section outlined developments in the educational field that led to recommendations for shorter university study courses. The situation in the health care field in the early 1970s created a readiness and desire on its part for educational programs at the university level. Within the health care field the only educational preparation to take place in the tertiary realm is that of the physician. Medical education is one of the three traditional profession's education to occur at the university. The study of medicine is a six-year course of rigorous study at the university level. The other health profes-sions, the nichtarztliche Berufe (literally, lithe nonmedical disci-plines"), all take place within the vocational/technical education system. These nonmedical disciplines include nursing, physical therapy, medical technology, dietetics, x-ray technology, and labora-tory assistance. One of the concerns of the Task Force of the Wissenschaftsrat was to narrow this gap in the preparatory education of the various health professionals. Members of the Task Force be­lieved that, just as individuals in a state of well-being can be situated on a health-illness continuum, so too can the educational preparation of the professionals qualified to care for these individ-uals with health needs also be situated on a continuum. They rejected the idea that there exists a clear distinction between medical care 67 and nursing care, and believed that one cannot and should not care for an organ in isolation from the whole person. Consequently the aim of the task force was to increase the educational mobilitY--hori­zontal and vertical--between these various health care fields. 10 Several other circumstances also contributed to the movement for reform in the educational preparation of health care professionals in the early 1970s. One was the indisputable shortage of nursing personnel. Aggravating the shortage situation was the expectation that qualified graduate nurses would supervise and teach students and other less prepared staff members on the hospital units, a task they were not educated to perform. This created the demand to adapt the education of nurses to the realities of these role expectations. While there existed a shortage in nursing personnel and insuf­ficient numbers of recruits entering the field to eliminate this, there were increased numbers of Abiturienten (those who had success-fully completed the Abitur) who wished to study at the higher education level, especially within the helping professions (sozialen Berufen) which included the health care field. ll Reform measures resulted in an increase of from 3-5 percent of an age group studying at the Gymnasium in the early 1960s to 15-20 percent in the 1970s.1 2 However, the only profession that could be studied at this level was medicine, which since the 1950s had had a serious over-load of applicants resulting in the imposition of a Numerus clausus, a restriction of the number of students admitted to the university for study in this field. One desire of the Task Force was to ameliorate the overload of students by making available other options for higher 68 educational study in the health field. Nursing and the other non-medical health professions were located outside the university at that (this) point in time and offered few upward mobility options. In summary, there was an openness and readiness for reform of nursing education on the part of some individuals, stemming from dissatisfaction with shortcomings in the existing basic and postbasic nursing education system. These shortcomings resulted in the desire for a more patient-centered nursing care, the desire to integrate nursing education more closely into the general education system, and, finally, the desire to tap into the enlarged pool of Abiturienten as potential candidates for the nursing profession. Conceptualization of the Modellversuch at the Free University of Berlin Failure of the (Original) Wissenschaftsrat Recommendations to be Applied to the Health Professions Almost as soon as the recommendations of the Wissenschaftsrat were made public, criticism from both within the field of nursing and outside it was heard. Among the most vocal of the groups were members of the medical profession who feared the creation of IIhalf doctors. 1113 Although some members of the Task Force planning these changes were physicians, and, although the draft was first approved by the Medical Committee of the Wissenschaftsrat, complaints of lIivory tower planningll from within medicine were nonetheless voiced. 14 It was not only the medical profession that was against such an innovation, but also many in nursing and medical technology. Nurses feared the creation of an elite within their own ranks. 69 Despite Task Force efforts to communicate the nature of these univer-sity study programs, it was not clear, especially from the proposed title, whether the graduate of these programs would be new health care professionals and whether these persons were under the jurisdiction of medicine or nursing. 15 In 1974 the Health Council (the Bundesgesundheitsrat)16 issued a clear rejection of the Wissenschafts-rat's recommendations but left the way open for reform and experi­mentation in the area of instructor education in these fields. 17 Planning at the Free University of Berlin Parallel to these various happenings, discussions were being conducted at the Free University of Berlin (FUB) exploring its role in the reform of professional education. As early as 1971, members of the Central Planning Committee of the FUB met to discuss the signifi-cance of the "Recommendations of the Wissenschaftsrat for the Structure and Improvement of Higher Education after 1970. 1118 In an opinion of the Medical Subcommission of the Standing Commission for Development and Planning, the integration of short-study courses for the health care professions at the FUB was supported. It was specifically emphasized that medicine should be excluded from these considera-tions-- that is, shortening the medical studies program was not an option to be considered. During 1973 "The Guidelines for Expansion Planning in the Health Disciplines at the FUB/Comprehensive Plan? was prepared and on 12 December 1973 was passed by the Academic Senate. On 2 February 1974 the University's Kuratorium, a joint decision-making body made 70 up of representatives of the university and the government19 approved them also. Included were the following guidelines: (1) a larger student capacity at the university should include the creation of new university-level courses of study for the health professions; (2) establishment of courses for the health professions, such as nursing, physical therapy, and medical technology, should be coor­dinated with the already existing programs outside the university system; and (3) close attention should be paid to the development of comprehensive higher education institutions and the role these might play in any reform. The report of the Medical Planning Group of the Central Planning Committee was then presented to the Medical Subcommittee, and two main points were discussed: (1) To what extent can the particular education tracks be unified? and (2) Which can be incor­porated at the FUB?20 It was decided to discuss these ideas with the various groups concerned, including the government administration, to see how much support existed. At the invitation of the president of the FUB, a meeting took place on 18 December 1974 with representa­tives of the following persons and groups: the Senator21 for Health and Environmental Protection; the Senator for Science and Art; the Nursing School at the Klinikum Steglitz; the Central Continuing Education Department of the Klinikum Steglitz; the Klinik Phonix; the Gewerkschaft oTV, the trade union representing nurses and other health professional groups; and the Central Planning Committee of the FUB. 22 Short-range and long-range decisions were made in this group. 71 It was agreed to place emphasis in the short term on reform of the existing basic and postbasic education system. For the long term it was agreed to consider the development of programs for new roles within the health care field, such as nursing management and supervi­sion of medical technological apparatuses in intensive care units. Study courses would also be considered in the long term for instruc­tion in medical sociology, medical psychology, and medical pedagogy.23 For the first time, even if only as one possibility among many, instructor education in the health professions was discussed. Also discussed were the difficulties in developing new courses of study, entrance requirements, insuring mobility between fields, and the danger of dequalifying the existing study courses. A representative of the Senatsverwaltung Science24 said that her office would support the development of testing of new study courses, as long as they followed the guidelines set down in the plans for development in education and higher education (the Hochschulenen­twicklungsplan and the Bildungsgesamtplan). The representatives of the Senator for Health and Environmental Protection stated it was not possible to give an endorsement at this time. 25 There existed no guidelines for the development of new courses of study, and, addi­tionally, the Conference of the State Health Ministers had taken a negative stand with respect to the recommendations from the Wissenschaftsrat. Instead, as mentioned earlier, the Conference recommended a postbasic course in the secondary education system II (see Figure 1; "Sekundarstufe II") that would be bound to the tertiary area and which would be nationally uniform and regulated by Lander 72 laws. The Berlin Health Senator was in complete agreement with this latter proposal. At a discussion on 12 December 1975 with representatives of the Central Planning Committee of the FUB and the Senatsverwaltungen Health and Science, it was made clear that a Modellversuch from the FUB would receive the support of the Health Senator only if it con­cerned itself with a study course for instructors. This was later confirmed in writing on 4 March 1975. 26 Further discussions with officials in various government ministries led to the assessment that the chances for approval of a three-year study course for instructors in the health professions were good. Discussions were also conducted within the university with members of the various departments concerned in order to win their support. The president of the FUB informed the Senator for Science and Art of his decision to submit a proposal for a Modellversuch on 11 July 1975. 27 On 15 December 1975 the necessary paperwork was com­pleted and sent to the Federal-States-Commission for Educational Planning. The proposal set forth the following schedule: Planning Phase: April 1976-September 1977 Implementation Phase: October 1977-September 1980 Evaluation Phase: October 1980-September 1981.28 An Elaboration of the Social Context Before proceeding to the presentation of the data relevant to the implementation of the Modellversuch, elaboration is needed about the general political and socioeconomic context of the Modellversuch. 73 The individuals interviewed for this study were in agreement that educational policy reforms, shortcomings in the existing nursing edu­cation and postbasic nursing education system, and a favorable con­stellation of other factors led to the time being right (ripe) for the planning and subsequent approval of the Modellversuch at the FUB. 29 The responses in the interview