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Definition

Nursing education refers to formal learning and training in the science of nursing. This includes the functions and duties in the physical care of patients, and a combination of different disciplines that both accelerates the patient's return to health and helps maintain it.

Description

Nursing and nursing education have undergone striking changes over the centuries. This history reveals a constant struggle for autonomy and professionalism. There have been many influences on nursing practice in the past, including women's struggle for professional acceptance and status, religion, war, technology, and societal attitudes. These factors still influence nursing today. During the past decades, the profession worked to improve its image.

Nursing education in the United States had its beginnings in Europe. In 1836, in Kaiserwerth, Germany, Theodor Fliedner opened a small hospital and training school called the Order of Deaconesses. Florence Nightingale, the founder of modern nursing, received her formal training at this school. In 1859, she published Notes on Nursing: What It Is and What It Is Not in London. This was not intended as a text for nurses but for the ordinary woman who was the nurse for her family. In 1869, voting rights for women were promoted with the organization of the National Women's Suffrage Association and Lavinia Dock, a nurse, used the organization to promote and expand nurses' rights.

The first training schools in the United States were opened in 1872 in Philadelphia at the Women's Hospital, and in Boston at the New England Hospital for Women and Children in Boston. Linda Richards, American's first trained nurse, graduated from the latter in 1873. The American National Red Cross was organized by Clara Barton in 1882, and in 1885 Clara Weeks Shaw published the first textbook written by an American nurse: Textbook of Nursing for the Use of Training Schools, Families, and Private Students. The first home visiting nursing organization in the United States, the Henry Street Settlement in New York, was founded by Lillian Wald and Mary Brewster in 1893. In that same year, the American Society of Superintendents of Training Schools for Nurses (renamed the National League of Nursing Education in 1912), was established.

The Nurses' Associated Alumnae of United States and Canada was established in 1897 and renamed the American Nurses Association in 1911. North Carolina, New Jersey, Virginia, and New York established the first Nurse Practice Acts in 1903. In a study funded by the Rockefeller Foundation in 1920, the Goldmark Report recommended that nursing schools become independent of hospitals, and that students should not be a source of cheap labor. It also advocated financial support of university-based nursing schools.

During the Great Depression, many nurses were unemployed and the number of schools declined, but the outbreak of World War II brought a huge increase in nursing demand. During the war years, new students were still taught by experienced nurses in hospital-based programs called diploma schools of nursing.

In 1948 the Brown Report recommended that education for nursing take place in colleges and universities, not hospitals. In the same year, the National League of Nursing Education established the National Nursing Accrediting Service for nursing educational programs. In 1951, Dr. Mildred Montag suggested that one way to increase the number of nurses was to shorten their education period. She also recommended that they be trained in colleges and universities instead of diploma schools. In her dissertation "The Education of Nursing Technicians," she proposed a two-tiered system in which "technical" nurses, who would be trained for two years, largely in community colleges, would assist "professional" nurses, who would receive four-year degrees. Although the model was not adopted at that time, Dr. Montag's paper is credited with creating the associate degree in nursing.

In 1965, the American Nurses' Association (ANA) published a position paper urged that all nursing education should take place in institutions of higher learning. As a result, many diploma schools closed and nursing education began its move to collegiate programs. At this time, the ANA also echoed Dr. Montag's proposal that nursing practice consist of two levels: a professional nurse, who would hold a baccalaureate or higher degree, and a technical nurse, who would have an associate degree and would work under the direct supervision of the professional nurse. Since then, as medical knowledge advanced, nurses have had to keep up with new medications, technology, and a rapidly changing health care system as well as appropriate nursing care.

Degree programs

Associate degree programs were originally introduced in the United States in 1952 and are primarily offered by community colleges. This is a two-year program emphasizing technical skills with a foundation in behavioral and biological science. Associate degree graduates take a state licensing examination and are entitled to practice using the initials RN. Since the 1950s, the National League for Nursing (NLN) has been the accrediting body for two and four-year nursing colleges. In recent years, though, four-year colleges have turned to the American Association of Colleges of Nursing (AACN) for their accreditation, an association that does not allow two-year colleges to join.

The baccalaureate program, found in universities and colleges across the United States, takes four years to complete. It provides an education in the arts, sciences, and humanities. Although the program teaches bedside care, the emphasis is placed on leadership and management, community health nursing, and research. These graduates also take the licensing examination and receive the designation of RN.

Advanced practice nurses are RNs who specialize in one of several fields, which include nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). These nurses have four-year degrees with at least some postgraduate study; most hold master's degrees. Like RNs, advanced practice nurses are licensed and certified.

To obtain a master's or doctoral degree, a student is required to hold a baccalaureate degree from an accredited college or university. Graduate programs emphasize advanced clinical practice, research, and prepare students for roles as educators and administrators.

Nurses can also serve without a college degree. Becoming a practical nurse takes about one year and is comprised of training in a hospital along with classroom work. After graduating from a practical nursing program, students must pass a licensing examination, after which they can use the initials LPN (licensed practical nurse) or LVN (licensed vocational nurse) and practice under the supervision of a registered nurse. Compared to RNs, however, LPNs make less money, have less responsibility, and usually are not promoted to supervisory roles.

Of the 2.6 million registered nurses in the United States, 32% have an associate's degree, 27% have a diploma, and 31% have a baccalaureate degree as their highest degree. In 1995, 61% of all new nursing graduates were from associate degree programs, slightly more than 9% had master's degrees and less than 1% held doctorates. In 1998, the Veteran's Administration, one of the nation's largest employers of nurses, stated that they preferred to hire nurses with baccalaureate degrees, but would not require one for entry-level positions. In that year, the VA set aside $10 million for each of the following five years to help associate degree nurses on staff go back to school to obtain a baccalaureate degree. Although many nurses consider their associate degree a valuable first step, higher degrees are necessary to enhance their prospects for advancement.

The nursing shortage

Health care has become a complex business; nurses are becoming managers who are expected to have the education and skill to provide leadership in administrative settings. At the same time, their workloads have increased and the patients for whom they care are moreill. In addition, many other professions are now open to women, diluting the pool of available candidates. The profession is also facing a shortage of nursing faculty. As a result, the number of nurses in the field is dropping, creating a significant shortage.

The average age of all RNs in 1996 was 44.3 years; for practicing nurses, 42.3 years. Worse still, the average age continues to increase at the same time that enrollment in baccalaureate programs is decreasing. Federal figures project that if current trends continue, rising demand will outstrip the supply of RNs in or about the year 2010. According to a U.S. Department of Health and Human Services Division Of Nursing projection, 114,000 jobs for full-time RNs will go unfulfilled in the year 2015.

To meet these future needs, hospitals and other employers have stepped up recruitment. The nursing practice has also been moving away from the acute care setting. Nurses have more opportunities in the community, advanced practice settings, health maintenance organizations, insurance companies and home health, and administrators are now requiring new employees to be bachelor's prepared.

Viewpoints

Changing curriculum

The capacity to develop critical thinkers and proactive professional nurses is driving all aspects of the education process. The scope is broad and highly technical, while requiring knowledge of social change and community development and all specialties in between. Theory and practice are also changing at rates that require nurses to continue their education throughout their careers along with retaining basic nursing values. Nursing practice should foster these attributes in a health care system of challenge and change.

Leading nursing organizations view a bachelor of science degree in nursing as the first step towards a career in professional nursing, and as a requirement for anyone seeking a position as nurse manager or supervisor. Nurses with a baccalaureate degree are prepared to practice in all health care settings, giving graduates a broader employment choice. This level of education includes health care policy, economics, research, outcome measures, quality indicators, fiscal management, legislative advocacy, and managing information systems.

LONG-DISTANCE LEARNING. Nursing students can now obtain an education from anywhere in the world, increasing competition and pressure for quality teaching. The Internet offers a wide range of information, available faster than ever before, along with a choice of curricula, with clinical practice based in the student's community. In addition, today's more diverse and demanding student body expects choices and educational methods that fit in with all aspects of their lives. As institutes of higher learning become increasingly more responsive to education consumers, students will expect flexible learning opportunities in settings that fit their multiple roles as employees, homemakers, and members of communities. Needless to say, all nursing education programs, whatever their format, should foster collaboration, nourish racial and ethnic diversity, and encourage men to enter nursing programs. Mentoring programs starting at the high school level would also encourage more nurses to join the profession.

Professional implications

Nurses at all levels are required to deliver high-quality service while containing costs. To this end, nursing education must foster innovation and prepare students to be critical thinkers and problem solvers. Nursing professionals must be able to search for new solutions, be proactive, and entrepreneurial. Continuous learning for the professional nurse is no longer just a task needed for license renewal, but is critical to staying current in today's nursing workforce.

Legislation is constantly changing the scope of nursing practice, and educators should reflect this in their curriculum. Nursing education shapes practice—it doesn't simply react to changes in government and care environments. Collaboration between nursing educators and practicing nurses to shape nursing curriculum should reflect nursing core values and ethics. Nurses who possess analytical, communicative, and negotiating skills can help improve the health care system by educating both the public and government policymakers.

Teachers must prepare nurses to work in highly technical settings, to be computer literate, and to be highly organized and self-directed. Knowledge of today's advanced medical science is communicated in complex and sophisticated ways, requiring all nursing professionals to have the ability to manage, retrieve, and interpret data, and to be autonomous and flexible. Educators will be obliged to teach technology solutions as well as enhanced personal services. Both students and teachers must be flexible in the ways they teach and learn.

There is also greater demand for nurses in specialty areas: critical care, operating room, radiology special procedures, neonatal, and emergency. Therefore, delivering a more complex level of care is extremely important. Nurses with advanced clinical skills will have greater opportunity in their choice of clinical environments, though they may have to pursue employment in a region other than their own community. Advanced practice nurses are in increasing demand across the United States and in other countries.

Educating future generations of nursing professionals will be a unique challenge in the next decade. While the nursing shortage is just beginning to be felt, nursing faculty may face a decrease as profound as the general nursing shortage. If and when a new generation of students can be persuaded to join the profession, an associate's degree would be the fastest and most economical way into the profession. If only a limited number of faculty are available, this will perpetuate the general shortage. Nursing roles in leadership and legislation will also be severely curtailed.

Many strategies have been suggested to counter the nursing and faculty shortage. Recruiting and retention committees are the focus of many educational institutions and health care facilities in the United States and internationally. Both shortages must addressed because one can not be maintained without the other. The challenge will be a unique and challenging endeavor for the future of nursing education and will doubtless have a major global impact on health care.

René Jackson, R.N.