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.[1-3] Moreover, more evidence is being generated that supports the nurse’s level of education makes a significant impact on patient outcomes. 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.
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 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 20th 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.
Graduate education for nurses was introduced in the second half of the 20th century, with Rutgers University in New Jersey offering ‘a master’s degree in psychiatric nursing.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
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. 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.
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.
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.
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.How well countries are doing, along with issues encountered, are present in the literature. 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. 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.
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.
1. Institute of Medicine. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press 2011.
2. Department of Human Resources for Health, World Health Organization. Global standards for the initial education of professional nurses and midwives. Geneva, Switzerland: World Health Organization (WHO/HRH/HPN/08.6) 2009.
3. Frontline care: The future of nursing and midwifery in England (2010). Report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England. Available from: http://cnm.independent.gov.uk [Last accessed on 2012 Jun 0
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