Nursing education

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.

Resources

PERIODICALS

Arnovitz, F. "Competition for the Education of Nurses." Community College Week (October 2000): 13–16.

Happell, B. "Nurse Education: Is It Responding to the Forces of Supply and Demand?" Nursing Economics 17, no. 5 (September/October 1999): 252–256.

Lindeman, C. "A Vision for Nursing Education." Creative Nursing (January/February 1996): 2–5.

Lordes, E. "Two Years or Four? The Question Splits Nursing Education." Chronicles of Higher Education (September 1999): 46–55.

Richards, J. "Nursing in a Digital Age." Nursing Informatics 19, no.1 (January/February 2001): 6 ff.

OTHER

Hinshaw, A. "A Continuing Challenge: The Shortage of Educationally Prepared Nursing Faculty." Online Journal of Issues in Nursing. <http://www.nursingworld.org/ojin/topic14/tpc14_3.htm>.

ORGANIZATIONS

American Association of Colleges of Nursing. 1 Dupont Circle, NW, Suite 530, Washington, DC 20036. (202) 463-6930.

René Jackson, R.N.

Nursing Education

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 accelerate the patient's return to health and help 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. 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 urging 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 more seriously ill. 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 does not 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.

Resources

PERIODICALS

Arnovitz, F. "Competition for the Education of Nurses." Community College Week (October 2000): 13-16.

Happell, B. "Nurse Education: Is It Responding to the Forces of Supply and Demand?" Nursing Economics 17, no. 5 (September/October 1999): 252-256.

Lindeman, C. "A Vision for Nursing Education." Creative Nursing (January/February 1996): 2-5.

Lordes, E. "Two Years or Four? The Question Splits Nursing Education." Chronicles of Higher Education (September 1999): 46-55.

Richards, J. "Nursing in a Digital Age." Nursing Informatics 19, no.1 (January/February 2001): 6 ff.

OTHER

Hinshaw, A. "A Continuing Challenge: The Shortage of Educationally Prepared Nursing Faculty." Online Journal of Issues in Nursing. 〈http://www.nursingworld.org/ojin/topic14/tpc14_3.htm〉.

ORGANIZATIONS

American Association of Colleges of Nursing. 1 Dupont Circle, NW, Suite 530, Washington, DC 20036. (202) 463-6930.

NURSING EDUCATION

To place nursing education into perspective, it is helpful to reflect on the health care environment and the role of the nurse in that environment. The health care landscape in the United States has been changing at an unprecedented rate. Nursing education also has undergone changes to keep pace and to prepare leaders who are highly educated and technically sharp decision-makers and clinicians. What is most noteworthy, however, is not that change has occurred but rather that the rate of change since 1980 has been greater than during similar periods. Factors driving the transformations include new medical and technological advances, new health care delivery systems, and expanded roles for nurses.

Nurses are the largest single group of health care professionals but they do not practice in isolation. Rather they are an integral part of health care teams, institutions, and systems. As health care continues to move outside the hospital, the demand for nurses who can function across systems and direct a continuum of care is rising. The changing health care environment has not only changed the role of the nurse, it has also affected the supply–demand ratio. Hospitalized patients have multiple health problems, are more acutely ill, and are discharged sooner. This has increased the demand for nurses in acute care institutions at the same time that more nurses are needed in home and community settings. Given trends that emphasize health promotion and disease prevention, the need for acute and chronic care is skyrocketing.

The Federal Division of Nursing predicts that by 2010, the growing demand for nurses with bachelor of science in nursing (B.S.N.) and master of science in nursing (M.S.N.) degrees will outstrip the supply and that by 2020, the demand for B.S.N. and M.S.N. graduates will grow nearly twice as fast as the expected increase in the workforce. The predicted need for nurses is sobering, yet it is important to acknowledge that the impending crisis is not solely numbers based. The question is not only how many nurses will be available, but more importantly, will their educational preparation be appropriate to meet future health care needs. Based on the Federal Nursing Division's data, the answer is to increase the number of bachelor's, master's, and doctorate-level nurses.

Bachelor of Science in Nursing Degree

In 1996 the American Association of Colleges of Nursing affirmed nursing's place in American higher education by stating that the minimum educational requirement for professional nursing is the bachelor of science in nursing (B.S.N.) degree. B.S.N. programs are offered by four-year colleges and universities. Most generic B.S.N. programs are four academic years, although some students who have other responsibilities may choose to extend their programs. The term generic refers to a program designed for students studying nursing for the first time. By comparison, some B.S.N. programs have degree completion tracks for registered nurses (RNs) and licensed practical nurses (LPNs) who have completed basic nursing programs in hospitals or community colleges. Some programs also offer tracks for individuals with bachelor's degrees in other majors. B.S.N. programs must be approved by the state board of nursing.

A B.S.N. degree enables graduates to not only launch a successful career in nursing, but also to appreciate a more meaningful life. Therefore, the curriculum includes courses in nursing as well as the arts and sciences. Because the B.S.N. graduate is prepared as a generalist, nursing courses include both theory and clinical experiences and in most specialty areas, such as adult, community, maternal-child, pediatric, psychiatric, and critical care nursing. In some B.S.N. programs, students enroll in nursing courses at the freshman or sophomore level with courses in the major along with arts and sciences integrated throughout the program. In other programs, nursing courses are concentrated at the junior and senior levels. The number of credit hours required for a B.S.N. degree usually ranges from 120 to 130. Upon completing the degree, graduates are eligible to take the National Council Licensing Examination (NCLEX) to become licensed as a registered nurse. By law, nurses must be licensed to practice in the state where they work.

A strong background in science, mathematics, and verbal skills is needed to succeed in nursing. The admission process varies among institutions but typical criteria include: official transcripts with a minimum grade point average (GPA) of 2.0; SAT or ACT Assessment score, and TOEFL (Test of English as a Foreign Language) for foreign students; essay; and letters of recommendation. Some B.S.N. programs admit students directly into the major. Others admit students initially to the institution and require students to apply for admission to the major after completing prerequisite courses including the sciences.

Master of Science in Nursing Degree

Whereas bachelor's degree graduates are generalists, master's degree graduates are specialists. The master of science in nursing (M.S.N.) degree program prepares graduates to be advanced practice nurses (APNs) with in-depth theory and practice in a clinical specialty. Some M.S.N. programs combine both clinical and functional roles (e.g. education, administration, case management). However, the American Association of Colleges of Nursing (1996) concluded that the clinical role should be the primary focus for all master's programs.

Most master's students select one of four tracks or primary roles: clinical nurse specialist (CNS), nurse practitioner (NP), certified registered nurse anesthetist (CRNA), or certified nurse midwife (CNM). The CNS is an APN with expertise in theory and research-based clinical nursing practice. In addition to clinical practice, major roles of the CNS include teaching, research, consulting, and management, all within an area of specialization, such as acute care, adult health, community health, critical care, gerontology, maternal-child, mental health, neonatology, oncology, pediatrics, or women's health. The NP is an APN who is a primary care provider to individuals and families in multiple settings. Originally developed to function as a physician extender, the NP role has evolved to incorporate a more holistic nursing approach to illness prevention and health promotion. NPs assess, diagnose, treat, prescribe, monitor, and refer patients as appropriate. The CRNA works closely with a physician and administers anesthesia in hospitals and outpatient settings. The CNM manages routine obstetrical cases. APNs have a collaborative agreement with a physician.

Although M.S.N. programs offer a wide choice of clinical specialties, most curricula include core courses such as statistics, research, professional role, concepts and theories, health policy, ethics, and economics. Other required courses include advanced study in physiology and pathology, pharmacology, and health assessment. The number of clinical hours is program specific but ranges between 500 and 750 are common. M.S.N. programs may require a thesis or other culminating project, and a comprehensive examination. The number of credit hours required for the M.S.N. degree typically ranges from 36 to 48. Although the master of science in nursing (M.S.N.) is the degree awarded most frequently, some institutions award a master of nursing (M.N.), a master of science (M.S.), or a master of arts (M.A.) degree. The difference is more a function of institutional organization, not the graduate nursing curriculum.

The admission process is institution specific but typical admission criteria include the following: official transcript verifying a B.S.N. degree from an accredited program with a minimum GPA of 3.0; undergraduate courses or demonstrated competency in health assessment, statistics, and informatics; practice in nursing; Graduate Record Exam (GRE), Miller Analogy Test (MAT), or TOEFL for foreign students; letters of recommendation; résumé; and an essay. The above discussion assumes that a M.S.N. applicant has a B.S.N. degree, but it is possible for nurses with no bachelor's degree or a non-nursing bachelor's degree, and for individuals with no background in nursing to be admitted into some graduate nursing degree programs.

After completing a master's degree or postmaster's certificate, CNSs and NPs may take national certifying examinations such as those offered by the American Nurses Credentialing Center (ANCC) providing their programs included the requisite content and hours in a clinical specialty. This credentialing system further demonstrates nursing's everincreasing standards and commitment to excellence.

Doctoral Degrees in Nursing

The quality of nursing education has increased further as evidenced by the fact that doctoral degree programs in nursing, and even postdoctoral programs, have become an integral part of American higher education. Prior to 1960 there were no doctoral programs in nursing. During the 1960s nursing was added as a minor to other Ph.D. degree programs. It was not until 1970 that Ph.D. programs in nursing emerged, but the number of programs has increased significantly. At the beginning of the twenty-first century, there are more than seventy-five doctoral programs in nursing leading to a Doctor of Philosophy (Ph.D.) or a Doctor of Science in Nursing (D.N.S., D.S.N., or D.N.Sc.) degree.

Both the Ph.D. and D.N.S. degree programs focus on research and "prepare students to pursue intellectual inquiry and conduct independent research for the purpose of extending knowledge" (American Association of Colleges of Nursing, 2001b, p. 2). Stated differently, doctoral programs in nursing enhance the scientific foundation for nursing theory and practice. A research-focused doctoral degree prepares graduates for a variety of positions within higher education, health care, government, and the private sector, such as educator, researcher, administrator, and advanced practice. Career options for nurses prepared at the doctoral level are virtually limitless.

Directed toward preparing graduates for a wide range of scholarly pursuits, most doctoral programs require courses in history, philosophy, and theory of nursing; informatics; research; and in related issues from health care ethics to economics. However, curricula do vary depending upon philosophy, faculty expertise, and other resources. Other requirements include a dissertation, oral defense, and comprehensive examination. The number of credit hours required for the doctoral degree is institution specific.

Criteria for admission to a doctoral program are similar to those for a master's program. Typical criteria include an official transcript verifying a M.S.N. degree with a minimum GPA of 3.0; a strong foundation in statistics; GRE score; practice in nursing; curriculum vitae; letters of recommendation; essay; and interview by a faculty committee.

Higher education is a lifelong investment. Undergraduate and graduate students should investigate several programs to determine which one correlates best with their academic and clinical interests and career goals. Students also should carefully assess multiple institution and program characteristics, especially accreditation status. Colleges and universities are accredited by nationally recognized, regional accrediting associations. Undergraduate and graduate nursing programs may apply for specialty accreditation by the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC). Although accreditation is voluntary, it demonstrates an institution's and program's commitment to continuous improvement and quality education.

See also: Medical Education.

bibliography

American Association of Colleges of Nursing. 1993. Position Statement on Nursing Education's Agenda for the Twenty-First Century. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1996. The Essentials of Master's Education for Advanced Practice Nursing. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1996. Position Statement on the Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1997. Position Statement on Vision of Baccalaureate and Graduate Nursing Education: The Next Decade. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1998. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 2001a. Envisioning Doctoral Education for the Future. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 2001b. Position Statement on Indicators of Quality in Research-Focused Doctoral Programs in Nursing. Washington, DC: American Association of Colleges of Nursing.

Anderson, Norma E. 1981. "The Historical Development of American Nursing Education." Journal of Nursing Education 20:18–36.

Bednash, Geraldine, ed. 2001. Ask a Nurse–From Home Remedies to Hospital Care. New York: Simon and Schuster Source.

Chaska, Norma L., ed. 2001. The Nursing Profession Tomorrow and Beyond. Thousand Oaks: Sage.

Hamric, Ann B.;Spross, Judith A.; and Hanson, Charlene M., eds. 2000. Advanced Nursing Practice. Philadelphia: Saunders.

Carole F. Cashion

Nursing Education

Nurses spend more time with patients who are facing the end of life (EOL) than any other member of the health care team. In hospice, nurses have been recognized as the cornerstone of palliative care, and it is increasingly apparent that nurses play an equally important role in palliative care across all settings. Studies have documented that nurses and other members of the health care team are inadequately prepared to care for patients with pain at the EOL. Inadequate care of the dying continues to be a problem in the twenty-first century. Many reasons have been cited for this failure, including inadequacies in the basic and continuing education of health care providers.

Challenges to EOL Care

Numerous studies during the 1980s and 1990s have documented that nurses lack knowledge about pain control, one key aspect of EOL care. Pain management has been described as a situation in which physicians continue to underprescribe, nurses inadequately assess and undermedicate patients, and patients take only a portion of the analgesics prescribed or underreport their pain. Generally, physicians and nurses have an inaccurate knowledge base about common pharmacologic agents used in pain control and have exaggerated fears about the likelihood of addiction. The fear of addiction continues to be a major obstacle to adequate treatment of pain at the EOL.

However, pain management is only one aspect of EOL care. Other EOL needs include management of other physical and psychological symptoms, communication with patients and families, preparation of the staff and family care at the time of death, and many other aspects of care of the dying. Attention to EOL issues, such as a report by the Institute of Medicine on EOL care and action by the U.S. Supreme Court on the right to die, have prompted a focus beyond pain management to include other dimensions of EOL care.

Improving EOL Care

Two milestones, a key EOL care project supported by the Robert Wood Johnson Foundation conducted between 1997 and 2000 and its resultant recommendations and the 1997 Institute of Medicine report on EOL care, have addressed these deficiencies, resulting in increased awareness of EOL issues and spurring changes to EOL care and nursing education.

The Robert Wood Johnson Foundation Project. The Robert Wood Johnson Foundation funded study was conducted by the City of Hope investigators. The overall purpose of this project was to strengthen nursing education to improve EOL care by accomplishing three goals: (1) to improve the content regarding EOL care included in major textbooks used in nursing education; (2) to insure the adequacy of content in EOL care as tested by the national nursing examination, the NCLEX; and (3) to support the key nursing organizations in their efforts to promote improved nursing education and practice in EOL care.

The primary activity for the first goal, improving the content regarding EOL care in nursing textbooks, was a review of fifty major textbooks used in nursing education. These fifty texts were selected from a list of over 700 textbooks used in schools of nursing, and then were stratified by topic areas. The areas selected and number of books included were AIDS/HIV (1), assessment/ diagnosis (3), communication (2), community/ home health (4), critical care (4), emergency (2), ethics/legal issues (5), fundamentals (3), gerontology (3), medical-surgical (5), oncology (2), patient education (2), pediatrics (3), pharmacology (4), psychiatric (3), and nursing review (4).

A detailed framework for analyzing the content of the textbooks was developed by the City of Hope investigators. This framework was based on a review of current literature and expert opinion about optimum EOL care. Nine critical content areas were selected: palliative care defined; quality of life (physical, psychological, social, and spiritual well being); pain; other symptom assessment/ management; communication with dying patients and their family members; role/needs of caregivers in EOL care; death; issues of policy, ethics, and law; and bereavement.

The fifty texts encompassed a total of 45,683 pages. Each text was reviewed using the framework. The reviewer scanned the complete index, table of contents, and all text pages for possible content. The reviewers were very inclusive and liberal in their approach, and when any EOL content was identified, those pages were copied. The copied pages then were analyzed for content using a "cutand-paste" approach in which the content was placed on the analysis grid within the appropriate framework section. Key findings of the study were:

• • Of the 45,683 pages of text reviewed, 902 pages were related to EOL content, representing only 2 percent of the total content.
• • Of 1,750 chapters included in the texts, 24 were related to EOL, representing 1.4 percent of all chapters.
• • The nine EOL topic areas reviewed were included infrequently in the texts' tables of contents or indexes. At least one chapter was devoted to an EOL-related topic in 30 percent of the texts.
• • The EOL topics with the poorest focus in the texts were quality-of-life issues at EOL and role/needs of family caregivers. The areas of strongest content were pain and policy/ ethics issues.
• • Overall, 74 percent of the content in the framework was found to be absent from the texts, 15 percent was present, and 11 percent was present and commendable.

Recommendations from this analysis were presented to a conference of publishers and the City of Hope investigators continue follow up with the editors of these texts and other books in order to improve EOL content in future editions. Major progress has been made to date and the textbook editors and authors have been very responsive.

The second goal of the project, ensuring the adequacy of content in EOL Care, as tested by the NCLEX exam, was also successfully implemented. City of Hope investigators worked with the staff of the National Council of State Boards of Nursing to increase the emphasis of EOL care within the exam to increase its priority for nursing education, and thus the knowledge of practicing nurses. Goal three, supporting key organizations in their efforts to promote nursing education and practice in EOL care, was also achieved. Many nursing organizations have been mobilized to address the deficiencies in EOL care.

In addition to studying nursing education, City of Hope nurse researchers also surveyed over 2,300 practicing nurses to determine their perspectives on EOL care. Respondents were asked to rate these dilemmas based on their occurrence as "not common," "somewhat common," or "very common." The most frequently occurring dilemmas were use of advance directives and preserving patient choice/self-determination, which 37 percent and 23 percent, respectively, cited as very common. Interestingly, 93 percent of respondents cited requests for assisted suicide and requests for euthanasia as not common dilemmas, and 6 percent cited these requests as somewhat common. More than one-third of all nurses reported seven of the nine dilemmas, excluding those of assisted suicide and euthanasia, as somewhat common or very common. Acknowledging the diversity in responses to these dilemmas is important. For example, although 37 percent of respondents reported use of advance directives as very common dilemmas, 31 percent of the respondents reported this area as not common.

Respondents were also asked to rate how much of a barrier each factor was to providing good EOL care in their settings. The items were rated as "not a barrier," "somewhat of a barrier," or "a severe barrier." Respondents most frequently cited "influence of managed care on end-of-life care" (25%) as a severe barrier followed closely by "lack of continuity of care across settings" (23%). The barriers that were reported as common and the diversity of these barriers illustrate the complexity of effective EOL care. The respondents identified not only system barriers (e.g., continuity of care, influence of managed care) but also cited patients' (70%) and family members' (73%) avoidance of death as somewhat of a barrier. Other prominent barriers were health care providers' lack of knowledge and personal discomfort with death.

Institute of Medicine report. The Institute of Medicine report on improving EOL care concluded with seven recommendations, two of which spoke directly to the need for improved professional knowledge:

• • Physicians, nurses, social workers, and other health care professionals must commit themselves to improving care for dying patients and using existing knowledge effectively to prevent and relieve pain and other symptoms.
• • Educators and other health care professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to provide good care for dying patients.

End-of-Life Nursing Consortium

The studies of the 1990s lead to the End-of-Life Nursing Education Consortium (ELNEC) project—a comprehensive, national education program to improve EOL care by nurses. Primary project goals include developing a core of expert nursing educators and coordinating national nursing education efforts in EOL care. This project points to the future of nursing education in the twenty-first century.

This three-and-a-half-year ELNEC project began in February 2000, and is a partnership of the American Association of Colleges of Nursing (AACN) and the City of Hope Cancer Center (COH). A primary goal of the project is to bring together leading nursing groups and perspectives to form a collaborative approach to improve EOL education and care. The ELNEC curriculum has been developed through the work of highly qualified subject matter experts serving as consultants, with extensive input from the advisory board and reviewers. Courses are designed to prepare educators to be instructional resources for their schools and organizations, and serve as a vital force in the dissemination of this important content.

ELNEC includes a total of eight courses, five of which are offered for baccalaureate and associate degree faculty who can then facilitate integration of EOL nursing care in basic nursing curricula. Two courses are planned for school-based, specialty organization, and independent nursing continuing education providers in order to influence practice of nurses in their target groups. The final course will be for state board of nursing representatives to strengthen their commitment to encourage end-of-life education and practice initiatives in their states. In addition, five regional ELNEC courses will be offered.

See also: Communication with Dying; Death Education; Pain and Pain Management; Symptoms and Symptom Management

Bibliography

American Association of Colleges of Nursing. A Peaceful Death. Report from the Robert Wood Johnson End-of-Life Care Roundtable. Washington, DC: Author, 1997.

American Nurses Association. Position Statement on Active Euthanasia and Assisted Suicide. Washington, DC: Author, 1994.

Ferrell, Betty R. "End-of-Life Care: How Well do We Serve Our Patients?" Nursing 28, no. 9 (1998):58–60.

Ferrell, Betty R., Marcia Grant, and Rose Virani. "Strengthening Nursing Education to Improve End-of-Life Care." Nursing Outlook 47, no. 6 (1999):252–256.

Ferrell, Betty, Rose Virani, and Marcia Grant. "Analysis of End-of-Life Content in Nursing Textbooks." Oncology Nursing Forum 26, no. 5 (1999):869–876.

Ferrell, Betty, Rose Virani, Marcia Grant, Patrick Coyne, and Gwen Uman. "Beyond the Supreme Court Decision: Nursing Perspectives on End-of-Life Care." Oncology Nursing Forum 27, no. 3 (2000): 445–455.

Field, Marilyn J., and Chris K. Cassel, eds. Approaching Death: Improving Care at the End of Life. Report of the Institute of Medicine Task Force. Washington, DC: National Academy Press, 1997.

Internet Resources

American Association of Colleges of Nursing. "ELNEC Project." In the American Association of Colleges of Nursing [web site]. Available from www.aacn.nche.edu/ELNEC.

BETTY R. FERRELL