"Only to the degree that we become educated do we gain relationships of depth and meaning to the encompassing world." J. Glenn Gray (1994)

A Vision for Nursing Education is a collective reflection of the ideas and values of the members and Board of Governors of the National League for Nursing who continue in the tradition of the past hundred years-assuring, as Isabel Hampton Robb first wrote in 1893, that the graduates of nursing programs are prepared to work with their head, hearts, and hands in harmony.

This work was developed in 1993 after listening to the conversations of NLN members in council meetings, programs, and committees; reading their literature and their resolutions; hearing their questions and their answers and receiving the comments and suggestions of individual faculty, administrators of nursing services, and students. It is as relevant in 2001 as it was when it was published in 1993.

This Vision is but one of the many with which the National League for Nursing began its second century of leadership in Nursing Education. That leadership rule continues with even greater strength today.

A Vision for Nursing Education

Executive Summary

I. Introduction

II. Nursling's Agenda for Health Care Reform

III. NLN's Vision For Nursing Education Reform

IV. The Context for Reform

V. The Nursing Education Environment: Emerging mission, Structure and Processes

VI. Summary

Executive Summary

Nursing’s vision for a health care system that ensures access, quality, and cost containment through a new approach to the delivery of care is within reach. The nursing education system required by that of new approach must move quickly to provide adequate numbers of appropriately prepared nurses.

Successful implementation of nursing’s approach to health care delivery requires:

1. Significant increases in the numbers of advanced nurse practitioners prepared to provide primary health care to communities and primary care services in group and interdisciplinary practices.
2. A shift in emphasis for all nursing education programs to ensure that all nurses-whatever their basic and graduate education and wherever they choose to practice-are prepared to function in a community-based, community-focused health care system.
3. An increase in the numbers of community nursing centers and their increased utilization as model clinical sites for nursing students.
4. An increase in the number of nursing faculty prepared to teach for a community-based, community-focused health care system.
5. A shift in emphasis for nursing research and an increase in the numbers of studies concerned with health promotion and disease prevention at the aggregate and community levels.
6. Targeted national initiatives to recruit and retain nurse providers, faculty, administrators and researchers from diverse racial, cultural, and ethnic backgrounds.

A Vision for Nursing Education

I. Introduction

The growing consensus between consumers and the nursing community regarding health care reform provides a clear vision of how the nursing education system must now be redirected or re-formed-to serve the health needs of the people in the context of the twenty-first century. The changes in health care delivery that have occurred in the last decades, together with those now being proposed, magnify the challenges for a nursing education system undergoing its own changes.

The proposed reform of nursing education occurs as higher education itself faces significant challenges in regard to its relevance and accountability to the public it serves. The academic community, which was once the isolated domain of scholars, now includes practitioners, community and business leaders, and representatives of the foundation and public policy worlds as active partners in meeting its mission. As a result, the very nature of scholarship and the faculty role are being reconsidered.

Within the broader context, nursing education has initiated a series of its own fundamental reforms: re-formulating its mission, structure, and processes to include constituencies other than educators and disciplines other than nursing alone.

II. Nursing’s Agenda for Health Care Reform

Nursing’s Agenda for Health Care Reform – the nursing community’s proactive position on how, where, and by whom health care should be delivered- ultimately depends for its success on a complimentary stance in the educational sector. As a parallel to the fundamental changes in the proposed delivery system, long held beliefs about the mission, structure, and processes of nursing education are called into question by nursing’s proposal for a consumer-driven community based system of primary care providers.

Nursing’s Agenda for Health Care Reform calls for a new approach to delivery-taking health care to the consumer who will be an increasingly informed participant in decisions affecting his or her care. Health care services will be more usually delivered, for example, at work and school-based clinics. While hospitals and other institutions will still be significant components of the health care system, they will no longer be either the central focus or dominant influence. The consumer will now assume that position.

With the public’s trust, nurses will also assume a new position within the proposed delivery system. Direct reimbursement for nursing services will position nurses, and make them even more directly accountable in the public eye. As nurses are encouraged to move into managed care arrangements, they will need different skills as administrators, managers, and coordinators of the care continuum in addition to the expertise necessary for providing primary care. Nursing’s Agenda for Health Care Reform calls upon nurse providers to radically redefine their clinical practice, loyalties, political allies, and power nexus. No less is now expected of nursing education and nurse educators.

Clearly, the nature of the demand for nurses changes significantly, from what has been the case until now. The proposed system is built upon the provider as a patient care manager-someone who combines the roles of patient advocate, knowledgeable advisor, triage officer, and access channel to the system; and someone who helps the patient and family choose wisely as they seek to assure their health and wellness.

III. NLN’S Vision For Nursing Education Reform

Because the supply of nurses needed for the proposed delivery system differs from the current profile in both numbers and kind, nurse educators are faced with designing or modifying programs and curricula to assure that the nursing profession can deliver on the promises made within the reforms proposed. A community based system calls on nurse educators to re-align their accountability away from institutions and agencies and toward populations. In so doing, the imperative of assuring that the graduates of their programs can deliver culturally competent care to the diverse populations who constitute those communities becomes more apparent; as does the responsibility to recruit and retain individuals from diverse racial, cultural, and ethnic populations.

Therefore, as the alternative delivery system is in the process of being realized, the nursing education community is preparing to:

1.- Increase the numbers of advanced nurse practitioners in order to meet the need for primary care providers across the country;

2.- Reform all nursing education programs to assure that graduates are competent to function in a delivery system where:
   a - The individual and the family have primary responsibility for health care decisions;
   b - Health and social issues are acknowledged as interactive; and
   c -Treatment effectiveness rather than the technologic imperative drives decisions;

3 - Re-define "nursing faculty" to include providers, re-socialize existing nursing faculty to the new roles appropriate for a community based system, and re-form their knowledge base and repertoire of pedagogical skills.

IV. The Context for Reform

In the educational sector, the reforms needed in nursing education are as dramatic and as far-reaching as those proposed for the delivery system. Fortunately, the political climate for changes in nursing education is as favorable as the climate for change in the delivery sector because of recent trends in the higher education, health professions, and nursing education communities. Of the many significant departures from past educational practices, the following are among those with specific implications for how nursing education might be reformed in support of the Agenda.

1. Higher Education. First, the national movement toward greater public accountability for all educational programs has moved educators to be increasingly concerned with the outcomes of their programs and the expected or guaranteed competencies of their graduates. Second, the disturbing results of international comparisons among U.S. graduates at both the secondary and post-secondary level have generated a national mood of reflection and introspection among educational policy makers. Third, there has been a broad-based national educational movement to reform curricula to those that are more socially relevant and particularly reflective of the diversity and plurality of local communities. Fourth, the increasingly high cost of a college education in both public and private institutions has led to the increased concerns for quality on the part of individual payers; and the public has begun to look with scrutiny on long-established practices such as the use of graduate students as faculty. Fifth, the economic exigencies of reduced resources challenge educational administrators. "Doing more with less" is the watchword as faculty develops new ways of teaching and advising. Many states have developed models of articulation between junior and senior colleges, and some are paying greater attention to a "seamless" educational system that encompasses K through PhD. In other states, all lower division courses are to be offered in community colleges.

2. - Education For Health Care Providers. Nursing education has engaged not only these issues of the broader educational community but those particular to the education of health care providers. First, technological advances that increase access to information calls for a fundamental reorientation of the definition of the definitions and assumptions of both professionalism and education. The industrial model, which differentiated technical from professional work, is increasingly archaic and dysfunctional. In its place are models built around the individual as a knowledge worker within a system that places priority on primary health care. Differentiation among graduates solely on the basis of degrees is being replaced with differentiation on the basis of the competencies needed in various patient situations and expected from the graduates of particular program

Second, contemporary research in professional education points toward developing pattern recognition and innovative response to problems rather than to the mastery of any soon to be archaic content through a didactic pedagogy. The ‘art of thinking’ is now considered an identical pattern, although in the varying stages of development, whether the individual is a beginning or graduate student. Such research suggests a continuum rather than qualitative distinctions between the expected competencies of students and graduates of different programs.

Third, several recent commissions have identified an expanded range of competencies needed by tomorrow’s health professionals. These competencies are increasingly not discipline specific, arguing more than ever before for a multidisciplinary approach, a broad and integrated knowledge base, and skills in collaboration, cooperation, and conflict resolution.

3. Nursing Education. In addition, assumptions about nursing education have been similarly transformed by research and realities that question any arbitrary distinctions and outdated dichotomies between theory and practice. For example, recent research in the area of clinical decision making has led to a renewed recognition of the knowledge imbedded in practice. Second, in contrast to the recent past, the profession now has a critical mass of clinicians with masters and post-masters education, prepared to serve as clinical faculty.

Furthermore, the era when the various pre-licensure nursing programs were distinct and self-contained entities has today been replaced by programmatic interaction and collaboration reinforced by state mandates for articulation agreements, a declining high school population, and the increasing numbers of second career students that characterize a national economy in transition. These new times lead to new ways of validating knowledge that are dependent neither on whether the courses are placed as an upper or lower division offering nor on their sequencing within a curriculum.

V. The Nursing Education Environment: Emerging Mission, Structure and Processes

1. The Emerging Mission. Increased public scrutiny matched with an intensified self-analysis has led nursing education to rethink its mission by re-thinking the traditional relationships among research, teaching, and community service. This triad has been at the heart of the university model first developed in eighteenth century Germany. What once served society well has become painfully out of touch with the complex issues of contemporary society. Research, teaching, and service rather than separate activities in the respective interest of the science, discipline, and professional community now need to assume new forms in the public interest and a more direct relationship to the community.

   The mission of nursing education turns increasingly not only to the promotion of quality care by educating qualified practitioners but to the creation of linkages that will allow the educational projects of its faulty and students to actually provide services. Both research and learning can be expected to focus more on community health needs than has been the case.

2. Emerging Community Based Structures. While some of nursing education will continue to take place in academic settings, increasingly more will occur in the practice setting-but a practice setting within the community. Parallel to the greater emphasis placed on community based delivery systems, nursing education programs will increasingly be structured so as to bring together the various constituencies concerned with the education of new nurses-the community, patients, current practitioners, students, and businesses-in addition to the traditional faculty.

   Educational experiences will be increasingly planned where people are: at home, in schools and work sites, in ambulatory settings, long term-care facilities, shelters and community gathering places, as well as in hospitals. Given the growing difference from community to community throughout the country, nursing education programs may appear increasingly dissimilar reflecting the particular characteristics and specific needs of their locales.

   Common to all programs, however, is the need to educate for the macro level of intervention rather than for micro individual situations, and for a greater authority, accountability, and responsibility, as well as a lesser reliance on institutional authority and policies.

3. Emerging Processes

1. Curricular Reform. There is a generally acknowledged impetus to revise nursing curricula so that they are more accountable to the public. These calls for reforms include: a theoretical pluralism rather than any one "politically correct" approach; caring and humanitarianism as core values rather than the domination of technology; and the centrality of the student-teacher relationship over esoteric scholarship.

Demographics argue for a major focus on care of the elderly and vulnerable populations as well as assurance state education provides a sensitivity and knowledge base that will inform care of diverse cultural and ethnic populations. Methods that increase students’ sensitivity to all these populations must be sought, studied, and implemented.

Curricula at all levels will need to prepare graduates for management roles in all modalities of care wherein they will be able to work with assistive personnel, volunteers, and friends and families in new and complex ways. Graduates need to be prepared for managed care in the interest of clients, as contrasted with insurance companies or corporations, and be able to access and manage financial, technical, and human resources.

Calls for curricula innovations have also identified several areas for special attention such as:

1. faculty-to-faculty to student relationships that are more egalitarian and characterized by cooperation and community building;
2. special attention to the multicultural, multiracial and growing diversity of both individual and family lifestyles;
3. incorporation of critique of the current health care system and an analysis of the present and future health needs of the population as the basis for transforming the health care system; and
4. substantial contact with and participation by consumer populations particularly those at health risk.

In addition, nursing education is working more closely than in recent history to match the needs of the emerging health care environment. Recent private studies, such as the Pew Commission, have identified trends within the larger environment that are of direct significance for education including:

1. acute-care hospitals becoming a collection of intensive care units;
2. the increasing prevalence of self-care facilities and a move to greater consumer self-reliance;
3. an increasing public pressure for public disclosure, consumer information, and involvement;
4. a burgeoning home health industry;
5. the demographic shifts with accompanying expectations of elder care and chronic illness;
6. the adoption of clinical practice guidelines that create a more prescriptive practice while at the same time increase the opportunity for autonomous practice;
7. limited financial, technical and human resources; and
8. increased competition in the marketplace.

While there is a tendency to approach curricular reform  focusing on which additional content and competencies ought be included, this inevitably leads to missing the forest for the trees.

The most significant reform involves process-the changed relationship to information on the part of faculty, student, and health care consumer. Technology has democratized information and in the process shifted the points of access and control from the professional to the educated public. With this shift then, the focus of education turns from content to

1. critical thinking
2. skills in collaboration,
3. shared decision making,
4. social epidemiological viewpoint, and
5. analyses and interventions at the systems and aggregate levels.

1. Faculty Reform. Critical to any discussion of educational reform is the recognition of the faculty as architects of curricula. Here, too, recent changes contribute to the receptive climate for educational reform especially as it relates to faculty scholarship. Nursing research has diversified considerably over the last two decades. With the exception of nurse anthropologists, nursing scholarship was once developed almost exclusively within the prevailing paradigm of the logical positivists. As it has matured, nursing scholarship has also broadened considerably. It now includes the work of qualitative methodologists, nurse philosophers and ethicists, historians, feminists, and most recently those working within Boyer’s description of the "scholarship of application."
2. The scholarship of Application. There is a particular advantage for nursing faculty in Boyer’s arguments for changing what is considered acceptable scholarship for appointment, promotion, and tenure within higher education. Of all the changes currently proposed, this has perhaps the greatest potential to reform higher education and advance Nursing’s Agenda. Boyer argues for research studies more directly relevant to the broader social issues facing our society and our communities to replace the dominance of those studies of interest only to the particular discipline and its sub-specialists. He argues that for society’s intellectual leadership to be more responsible and responsive it must address its attention to solving the concerns of daily living.

As a group, nursing faculty have demonstrated their abilities to be peer scholars within the academic community. Were they now to embrace the "scholarship of application" in addition to the more traditional definitions of scholarship, nursing faculty would be able to theoretically ground those projects within health care services provided as part of their teaching and their research. The cumulative effect will be a more inclusive view of what it means to be a scholar and an intellectual pluralism that allows the faculty the orientation necessary for the curricula reform already discussed.

There is, however, one major exception to all this reform that must be addressed before any changes can be effected. Namely, that faculty teach what they know, and at this stage, the majority of faculty know the current health care system. Too few have been introduced, either by education, experience, or research to a consumer-driven, community-based primary health care system and even fewer are facile with their role as educator for such a system.

In addition, as lacking as these numbers seem to leave us, they under-report the need. We cannot assume that the community health we know the community health nurses we have are what we need for the community health care that will emerge in the new system. Existing community and public health programs were developed for a different health care system than the one currently being proposed. The graduates of these programs, therefore, were prepared with the knowledge and skills needed for the soon-to-be-reformed system, In the context of the significant delivery reforms being proposed, these educational programs themselves need to be rejuvenated, reformed, or relocated; and their graduates need additional post-graduate exposure.

Before curricular reform, then, comes faculty reform. As called for in the Secretary’s Commission:

We need nursing faculty who do not only explore frontiers of new knowledge-but who also integrate ideas, connect thought to action, and inspire students…..

Post-graduate programs are needed that will expand the expertise of current faculty and increase their facility in the following areas:

1. extra-institutional clinical sites,
2. population-based care,
3. cooperative relationships with consumers,
4. principles and practices of public health,
5. interdisciplinary collaboration, and
6. new relationships to knowledge and technology.

Perhaps most importantly, faculty are urgently needed who are prepared to engage in research that will support and advance models that collapse the boundaries between education and practice, professional and patient, and those separating disciplines.

6. Summary

Significant changes in nursing education are needed if the profession is to deliver on the promise embedded in Nursing’s Agenda for Health Care Reform. In the past, nursing’s focus on community-based care was philosophical for the many and actual only for the few who chose to specialize. Now, however, the Agenda for Health Care Reform is being advanced as nursing’s alternative vision for health care delivery and community-based care is increasingly the generalist's rather than the specialist’ domain. Preparing all graduates of nursing education programs for community-based care, therefore, becomes the responsibility of all programs and all faculty. Perhaps in varying degrees, but a commonly shared responsibility nonetheless.

References

Boyer, Ernest L. Scholarship Reconsidered. Priorities of the Professorate. New Jersey, The Carnegie foundation for the Advancement of Teaching, 1990.

"Innovative Curricula." Resolution passed unanimously by NLN membership, 1989 Biennial Convention, Seattle, Washington

Nursing’s Agenda for Health Care Reform, 1991. Available from the National League for Nursing, 61 Broadway, NY, NY 10006.

Pew Health Professions Commission. Healthy America: Practitioners for 2005, An Agenda for Action for U.S. Health Professional Schools. Shugars, DA, O’Neil, EH, Bader, JD. Durham: The Pew Health Professions Commission, October, 1991.

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