|Year : 2014 | Volume
| Issue : 4 | Page : 136-141
Nursing education: The past, present and future
Karen H Morin
College of Nursing, University of Wisconsin-Milwaukee, Wisconsin, USA
|Date of Web Publication||13-Oct-2014|
Karen H Morin
Director of PhD Program, President, the Honor Society of Nursing, Sigma Theta Tau International, 2009-2011, PO Box 413, Milwaukee - 53201-0413, Wisconsin
Nurses constitute the greatest number of healthcare workers in the United States and globally. Increasingly, the role they play in meeting societal demands for safe, evidence-informed, quality care is being recognized. However, how they are educated around the world varies greatly. The purpose of the paper is provide a brief review of the evolution of nursing education in the United States and globally, describe the current and projected state of nursing education, and discuss some pressing challenges educators face as they strive to meet the charge to prepare nurses to care for more complex patients situated in ever-changing health-care systems.
Keywords: Nurses, nursing education, future challenges
|How to cite this article:|
Morin KH. Nursing education: The past, present and future. J Health Spec 2014;2:136-41
| Introduction|| |
Nurses constitute the greatest number of healthcare workers in the United States (US) and globally.  Increasingly, the role they play in meeting societal demands for safe, evidence-informed, quality care is being recognized. ,, Moreover, more evidence is being generated that supports the nurse's level of education makes a significant impact on patient outcomes. ,,,, These investigators report that patient mortality decreases when the number of nurses prepared at the baccalaureate level increased. However, Felber et al., report contrary results when non-US educated nurses are employed in US hospitals except in instances when 'patient-to-nurse ratios are lower than average' (p. 366).  Thus education may not be the only factor contributing to patient outcomes.
Nonetheless, despite increasing evidence, debate about what constitutes the most appropriate education for nurses continues in the US and elsewhere. In many countries, nurses continue to be educated by physicians, programmes of study are extremely short, and opportunities for continuing education are limited. In the US, an individual can choose one of three programmes for their initial education in nursing: Hospital-based, community college or 4-year college or university. The purposes of this article are to provide a brief overview of the evolution of nursing education, describe the current and projected state of nursing education, and discuss some pressing challenges that educators face as they strive to meet the charge to prepare nurses to care for more complex patients situated in ever-changing healthcare systems.
| Evolution of Nursing Education|| |
Donahue  in her illustrated history of nursing from ancient times, highlights times when the profession of nursing was either present or noticeably absent. While beyond the scope of this article, one must be cognizant of the impact societal changes have had on nursing education is critical to the discussion. Thus, issues such as disease, revolutions, and women's rights have helped drive the need for and education of nurses.
Although there are records of men and women nurses during early civilisations, most scholars consider the work done by Florence Nightingale connotes the birth of modern nursing. Her efforts had a profound impact on standards of nursing care , and on the education nurses received.  In fact, 'the school she established at St. Thomas Hospital served as a model of nursing education globally for many years' (p. 41).  Her model was one of apprenticeship, with considerable time being spent providing service in the form of patient care and less time in formal classroom experiences. Nonetheless, she is recognized for bringing 'an educated respectability to the occupation of clinical nursing making it an acceptable and legitimate career' (p. 2397). 
In the US, publication of the Brown report  highlighted continuing issues about the initial education of nurses. Brown 'recommended that nursing education provide more education and less service in order to make nursing based on science, and therefore more professional' (p. 99).  Her recommendation to create two levels of education, a practical nurse and a professional nurse, propelled the movement from hospital-based nursing education to institutions of higher learning, and placed curriculum oversight within the purview of nurses, rather than physicians. Interestingly, such a move was contrary to what was happening at the same time with medical education, where hospital education was merged with higher education.
The concept of different levels of educational preparation for nurses continued into the 1950s, during which a 2-year associate degree curriculum was put forth as a means of meeting workforce needs consequent to World War II  in addition to the existing hospital or university-based programmes. While others were in discussion, Mildred Montag put forth a 2-year curriculum designed to prepare semi-professionals who could provide safe patient care but who did not have the expertise of a nurse prepared at the baccalaureate level. This curriculum mode, situated in community colleges, was embraced enthusiastically by educators and remains a significant path chosen by those wishing to be nurses. Thus, for the last half of the 20 th century, nurses in the North America have had at least three options by which to become a nurse: Hospital-based education that awards a diploma; community college route, earning an associate degree; or 4-year colleges and universities, earning a baccalaureate degree. However, one of the major impediments to resolving this situation has been the lack of a licensing examination for each level of educational preparation. In other words, graduates of three different programmes are evaluated using the same measure. In the US, such regulatory constraints have seriously limited the profession's ability to resolve issues associated with the educational preparation of nurses.
The Bologna Declaration in 1999  set the course for undergraduate and graduate education in Europe, thus influencing how nurses are educated. Key to this declaration is the requirement that countries established similar educational standards to facilitate the mobility of graduates cross borders. For example, preparation at the bachelor's level is to occur in 3 years, rather than 4 as is currently practiced in other parts of the world. The Declaration has initiated significant changes in how nurses are educated in Europe. However, in many of the Eastern European countries, nurses continued to be prepared in high-schools and hospital-based programmes.
Graduate education for nurses was introduced in the second half of the 20 th century, with Rutgers University in New Jersey offering 'a master's degree in psychiatric nursing' (p. 40).  This action prompted the creation of other programmes based on specialization. For example, a student could obtain a master's degree in the specialty of education or paediatrics. By the mid-1980s, professional acceptance of the contributions made by nurses prepared at the graduate level had grown. Since then, master's programs have proliferated, with many preparing advanced practice registered nurses (APRNs).
Interestingly Scheckel reports 'doctoral education for nurses has existed since the 1902s' (p. 42).  In the US, the first such programme was offered by Teacher's College, Columbia University in 1924; the degree awarded was an Education Doctorate (EdD) and the area of focus was nursing education  , followed in 1927 by Johns Hopkins University, who awarded a PhD in psychology and counselling. In 1956, Columbia University (Teacher's College) offered a new degree, the Doctor of Nursing Science (DNS) with a focus on nursing science. Boston University and the University of California-San Francisco quickly followed with similar degrees. In the early 1970s, the University of Alabama at Birmingham launched a doctoral programme, awarding a Doctor of Science in Nursing (DSN). According to McKenna, Keeney, Kim and Park  , the first doctoral programme in the United Kingdom was in 1967. Over the course of several decades, doctoral programmes in nursing have been developed in Australia, Brazil, China, Japan, Jordan and Korea. In the US, several doctoral degrees have been created in nursing (PhD, DSN, DNS, DNSc), resulting in considerable confusion among nurse, the public and colleagues around the world.
In the early days of doctoral education for nurses, they initially obtained doctorates in disciplines other than nursing, as the scientific basis for the discipline was not well-developed. No longer is that the case. Nurse scientists generate clinically relevant information that has been funded by such institutions as the National Institutes of Health (NIH), the Canadian Institutes for Health Research (CIHR) and the National Institutes for Health Research (NIHR).
The present [2000 forward]
While there continues to be many ways by which countries address the initial preparation of nurses, all are committed to providing a workforce equipped to care for increasingly complex patients situated in increasingly complex healthcare systems. To that end, 'national (Institute of Medicine, 2010; Front Line Care, 2010) and global bodies (Department of Human Resources for Health, WHO, 2010) now recognize the need to increase the education level of nurses' (p. 361).  In the US, the Institute of Medicine's (IOM)  The Future of Nursing: Leading Change, Advancing Health report has had a significant impact on how nurses are prepared. Two recommendations are particularly relevant to nursing education. The first, that by 2020, 80% of nurses should initially be prepared at the baccalaureate level has galvanized nurse leaders and educators to develop innovative strategies. Healthcare organisations are increasing funding for nurses to return to obtain their baccalaureate degree. Educators are challenged to 'expand the capacity of ADRN-to-master's in nursing programme tracks' (p. 76). 
The second IOM recommendation relevant to nursing education calls for more nurses prepared at the doctoral level. Increasing the number of doctorally-prepared-nurses addresses two concerns: Having a sufficient faculty to educate the number of nurses needed to meet workforce demands, and having enough scientists to contribute to the discipline's knowledge base. The creation of the Doctor of Nursing Practice (DNP) degree is one attempt to address the faculty shortage, given that expert practice knowledge is required to educate students in initial pre-licensure programmes. 
The advent of the DNP degree in the US in 2006 provides an alternative doctoral degree for nurses.  Since then, the professional doctorate has been introduced in such countries as Australia and the United Kingdom. Envisioned as degree reflective of the highest professional practice, its creation and implementation has given rise to considerable discussion about types of doctoral education available. ,,,, Advocates believe the credential will help position advanced practice nurses better in terms of the care they provide, their ability to evaluate appropriate patient outcomes, and the leadership they can provide.  Opponents are concerned that this alternative degree will not only decrease the applicant pool for PhD programmes, thus jeopardizing the development of discipline specific knowledge, but also limit the number of available healthcare providers' consequent to the increased length of study. 
Internationally, the need for competent nurses and midwives has been stressed in the WHO's Strategic Directions for Strengthening Nursing and Midwifery 2010 - 2015  , in the Global Standards for the Initial Education of Professional Nurses and Midwives  and the Global Standards for Midwifery Education.  Such standards provide critical guidance to those countries where nursing education occurs outside institutions of education.
While the perspective presented in this paper is predominately that of North America, no discussion of the present state of nursing education would be complete without discussing efforts colleagues around the globe have made to elevate the education nurses receive. Some countries, such as Thailand, were able to move to education in institutions of higher education by a decree of their king. Other countries continue efforts to institutionalize the baccalaureate degree. For example, Gao, Wai-Chi and Cheng  , in their review of the literature on nursing education in China, concluded there was great variability in how nurses were educated with some being educated at the 'secondary, associate degree and baccalaureate level' (p. 1429) and suggested the associate degree as the minimum level of education. Partnerships with academic institutions in other parts of the work are assisting with the development of graduate education in China. For example, Nolan et al., describe a partnership between Johns Hopkins University School of Nursing and Peking Union Medical College that resulted in the development and successful launch of the 'first full-time doctoral programme for nurses in China' (p. 353). 
Graduate master's education, particularly in terms of advanced practice nursing, typically considered to include nurse practitioners, clinical nurse specialists, certified nurse midwives and certified registered nurse anaesthetists, has been embraced by nurses globally.  However, what constitutes that education varies by country, and not all countries offer graduate education? Nonetheless, recognition of its importance is evident in the literature. Zou, Li and Arthur report that, while graduate programmes have been in existence in China since 1992, issues exist: Healthcare professionals do not consider the discipline of nursing an equal, thus nursing is subjected to medical standards; articulation of what constitutes advanced practice nursing is lacking; and financial support for graduate education is limited.  These issues are supported by Ma et al.  These issues are not unique to nurses in China, as the education of nurses is often placed under the aegis of medicine in many countries. Doing so limits the unique impact nurses educated at the graduate level can have on patient outcomes.
Doctoral education of nurses is now fairly common. Typically, the degree awarded is the PhD. How well countries are doing, along with issues encountered, are present in the literature. For example, the state of PhD education for nurses in Jordan  , Brazil  , Japan , , and Korea  has been reported. Differences in doctoral education between regions, specifically between Europe and North America, have been highlighted by Kermand Dreher and Glasgow.  More doctoral programmes offer the option to begin doctoral study without obtaining a master's degree first. The advent of the BS-PhD and BS-DNP programmes have provided an opportunity to prepare scientists and practitioners who are younger and who will have a longer time to contribute to knowledge development and evidence translation.
The IOM  recommendation that nurses should practice to the level of their education, and the recommendation that more nurses need to be prepared at the doctoral level has had a significant impact on how the education of nurses is perceived in the US and elsewhere. Although nurses in some countries such as the US will continue to have choices relative to their initial level of education, more countries will move to the baccalaureate degree as the initial preparation for nurses. Moreover, greater emphasis will be placed on all nurses furthering their education, irrespective of their initial level of education. Thus identifying educational approaches that facilitate seamless transition from one level to another will be a priority.
Given faculty projections that call for an increased need consequent to faculty retirement, one can anticipate more nurses pursuing a doctoral degree. Having sufficient numbers of both professional practice doctorates (DNP) as well as research doctorates (PhD) will be essential to assure an adequate workforce prepared to care for a diverse patient population.
Although there have been significant advances in how nurses are educated, several challenges remain. The looming faculty shortage not only threatens the profession's ability to prepare nurses to meet societal healthcare needs, but equally important, it also highlights and increases the need to prepare nurses to assume faculty roles.
The presence of a variety of doctoral degrees can increase the public's confusion relative to each respective degree's contribution to health. The proliferation of programmes raises concerns about the quality of programmes, as well as the availability of needed resources for both students and faculty. Both Smeltzer et al.,  and Minneck et al.,  describe resource challenges consequent to the expansion of doctoral programmes as well as to the introduction of the practice doctorate.
How faculty approach teaching and learning has to change, given the explosion of information. Faculty will need to move from offering 'content-laden and highly structured curricula with an emphasis on behavioural outcomes fostering linear thinking' (p. 67)  to one that is concept-based, fostering skills that help organisation the myriad of information into meaningful learning, and refocusing learning so that it is student-centred. 
The need for creating opportunities for inter-professional education will only increase. Faculty will need to make concerted and consistent efforts to structure a variety of formal learning opportunities to foster an understanding of the contributions each member of the care team brings to meeting the needs of patients.
Lastly, educational systems must become more flexible and nimble in order to respond to changing societal needs. In other words, curriculum changes must be expedited so that graduates are prepared to meet changing needs of patients. No longer do we have the luxury to take two to three years to implement curricular changes.
| Conclusion|| |
Nursing education has evolved from an apprentice-style of education to one that requires an education grounded in liberal arts and calls for the development of critical thinking abilities. The evolution of nursing education has resulted in several approaches to initial preparation as well as the establishment of both master's and doctoral programmes. The creation of doctoral programmes has resulted in the preparation of nurse scientists who continue to make significant contributions to our understanding of the patient experience. The future of nursing education holds great promise, as the profession continues to be a critical partner in the healthcare team.
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