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Nurse education in the future: Will one size fit all?
Nurse Education Today (2005) 25, 251–254
Nurse Education Today intl.elsevierhealth.com/journals/nedt
GUEST EDITORIAL
Nurse education in the future: Will one size fit all?
Trying to second-guess what the future holds for nurse education has been a major pre-occupation for nursing over many decades. More recently, articles of this nature have tended to look at the short-term future effects of legislated policy and reform – thus the degree of accuracy has been quite marked when it comes to evaluating these speculations a few years down the line (i.e., Francis and Humphreys, 1998; Glen and Clark, 1999; Mcilfatrick, 2004). In this editorial, I propose a ‘leap of faith’ that projects the reader 10–20 years on, thus presenting a personal prediction of what nurse education (if we will still be calling it this) might look like then. As with any rhetorical muse, however, there can be no substance without an element of factual basis and so I present my speculations, where possible, against a current factual context. I will start with my most controversial prediction. Firstly, I predict that there will be no ‘specific’ nursing education in the medium-term future. In my mind, health professions or multiprofessional education will be the norm – at least in Western curricula and certainly within Higher Education institutions. You do not have to be a crystal-ball gazer though to see this one coming. At my previous university, proposals were in place some time ago to replace all ‘nursing-specific’ programmes with generic health professions modules that are open to all health care professional groups. Related discussions proposed a shared pre-qualifying one-year ‘common foundation programme’ for nursing and medical students. An all-graduate entry requirement for health professional groups, and the pre-requisite of continuing post-qualifying education, will further drive this situation (Birchenall, 2000).
0260-6917/$ - see front matter c 2005 Published by Elsevier Ltd. doi:10.1016/j.nedt.2005.04.001
Collaborative health professions education is already with us to varying degrees, with combined and shared pre- and post-qualifying programmes for medical and dentistry students, nurses and other professions allied to medicine (in some countries abbreviated to PAMs) in place for some (Horsburgh et al., 2001; Guest et al., 2002; Barr, 2002; Wharrad et al., 2002; Morison et al., 2003). No matter how daunting this change might appear, however, it does not represent a huge swing in direction for nursing education, other than in terms of the rationalisation, funding and administration of such programmes. Medical and PAM-related education programmes broadly share similar content and operate within similar structural frameworks i.e., the medical model. Alongside this, the blurring of health professions’ roles (discussed later) suggests, to me, a progressive symbiosis of all health care-orientated education into health professions education. I will also add here a further consideration in that I believe inter-professional health education will have to face up to aligning its curricula towards accepting non-health care staff and students into its midst. The acceptance of students from all walks of public life i.e., social, charitable, voluntary and business backgrounds and institutions, who do not necessarily want to become registered health practitioners but are interested in aspects of health service provision, is likely at some point. Many universities are being forced to rationalise educational programmes whereby modules and papers are essentially repeated many times in institutions, often unknowingly, by different departments and different lecturers. I argue that where this particularly needs to happen is within health care professional-orientated programmes.
252 It is unsustainable for universities to offer separate nursing, medicine, dietetic, physiotherapy, occupational therapy, podiatry, etc., programmes (administered and delivered by separate academic staff) within single institutions. What makes this situation particularly unsustainable is the blurring of discipline-specific roles and responsibilities between health professional groups and an obvious overlap of knowledge and skills (Wharrad et al., 2002). In a number of countries, and especially in the UK, a number of factors have been at play over recent years to produce this effect. Increasing lay and user involvement in determining health service policy provision, quality-based broad health service reform, the increasing amount of ‘celebrated’ medical malpractice, the advent of evidence-based collaborative practice and the rationalisation of doctors and nurses hours and roles, have all forced inevitable changes in the working practices of health care professional groups. Doctors are legislating for less working hours against the fact that they are becoming more socially accountable, as the profession has its ‘traditional’ practices publicly scrutinised. Subsequently, nurses are the natural successors to take on the responsibilities that medicine is wishing to, or is being forced to, discharge. Nurses are increasingly expected to take on a more biotechnical role through extended practices – thus producing a blurring of medical and nursing roles. Role titles, such as Consultant Nurse are already mirroring this fact and, similarly, issues centred on the role of Nurse Anaesthetists prevail (Fairley, 2003; Inglis, 2003). I predict that as health professional disciplines evolve further, this will eventually reflect a position where there is no significant difference between the role of a doctor and a nurse. Administrators, of both Higher Education and health service institutions will welcome this, in that such blurring of roles will raise the question – ‘why pay doctors far more than other health professional groups if their roles are similar?’ Picture if you will then, a single health care-orientated curriculum that delivers to both groups and all other health professional groups in the process. In fact, add the evolving roles of nurses and doctors together and we may have the eventual demise of both professions in their current form! Taking the above-mentioned situations further, what will career pathways look like for health professionals in the medium-term future? Generally, nurse education currently delivers a foundation course that is followed up by a ‘branch-specific’ discipline speciality. Following
Guest editorial registration, nurses can then specialise further in their chosen clinical discipline by undertaking post-qualifying programmes of study and/or clinical competence. I predict that this will change. As the role of applied medicine adapts to take on a broader and more holistic remit, such as complementary medicine, I predict that there will be less emphasis on specialised bio-clinically focused attributes. Competing against inevitable rationalisation agendas, current roles and responsibilities will be further undermined as health services seek to produce a ‘generic’ better-for-value health practitioner. Perhaps there will be a generic foundation programme for all health care professionals, which will then allow its students to choose a speciality branch on successful completion of the foundation requirements. Not a clinical discipline-specific branch though I hasten to add. Instead, the health care professional may choose their branch according to the career pathway that they want to pursue – which could be management, administration, research, academia, education, policy development, etc. Universities may even offer a curriculum that fits all of these aspects into health professions training as the main themes within a foundation programme. I have already argued the case, in NET, for a specific career route that develops the nurse as a career health policy-maker (Whitehead, 2003). Glen (2002) has also put forward the case for the marrying of health and social care professions in pursuing an academic career pathway. As well as the issue of what will happen to nursing students of the future, there also remains the question of what will become of nurse lecturers/academics. My belief is that, as much as nursing students will disappear, so too will nurse educators – at least in the Higher Education setting. Deans et al.’s (2003) study suggests that universities, if they actually want to, will have problems in the future recruiting suitably qualified or experienced nurse academics as they struggle with the dilemmas of fewer departments of nursing, static academic status, conflicting role obligations (i.e., clinical and scholarly) and economic rationalisation agendas. In line with predicted generic health professions curricula, however, there will be no need for nursing-specific lecturers. Existing nurse lecturers will presumably have to ally themselves to other disciplines as they seek to specialise in non-nursing-specific areas and, perhaps, align themselves to broader social and clinical-science-based careers. Glen and Clark (1999) have identified that the generalist role of the nurse educator has already been eroded by ‘highly qualified specialists’.
Guest editorial Barr (2002) identifies shifts in inter-professional education that have led to a move away from profession-specific lecturers towards generalists, as higher education managers seek to rationalise programmes and gain economies of scale. Therefore, nurse educators will either have to adapt to developing themselves as highly qualified ‘nonnursing specialists’ or see themselves replaced. In my field of public health and health promotion, I am more and more involved with non-nurses than I am with nurses. Sometimes this is imposed by evolving agendas, while other times it is actually in my best interests to actively pursue this course of action. I am sad to say that, on occasions, it has been necessary for me to distance myself from nursing in order to fulfill my required role. I do believe that there will still be a place for ‘traditional’ nurse lecturers, although not in the Higher Education setting. Nurse lecturers must pursue academic credibility in the Higher Education arena or be left behind (Glen and Clark, 1999). As things begin to come full circle in nursing education, I predict a return to nursingspecific programmes being delivered purely in the clinical setting for non-registered nurses. Perhaps here, against this type of scenario, we might again witness the return of the clinical nurse tutor role. Already, many universities are beginning to ‘farm out’ their nursing-based modules, papers and programmes to clinically based partnerships. I favour this, as in my mind, the best place to deliver clinically focused programmes is in the clinical setting and delivered by those who are most clinically credible – active clinical practitioners. In the UK, the advent of the National Health Service University (NHSU) looked set to speed up this process and possibly take university-based nurse education away from the universities (Mulholland, 2003; Cooper and Harrison, 2003), but recently its role and future, if any, has become much more blurred. In the mean time, as nursing education aligns itself more closely with medical education and other health professional groups, nursing students will need to become far more conversant with independent learning strategies that will see them using more and more technology and health informatics-based teaching, virtual instruction (web-based portal and conferencing interventions), virtual laboratories for skills learning and various e-learning strategies (Wharrad et al., 2002). All of the above-mentioned situations, I believe, will set a precedent for the way that nurse education will be delivered in the future. New scopes for educational delivery will further speed up the requirements for new mind-sets,
253 new ways of delivering education, a new type of lecturer/academic and a new type of clinical workforce. So, I predict lots of radical change for nurse education and I predict its eventual demise over the next 20 years or so. I know that such a prediction will have me waving in the wind and I can also envisage the degree of consternation that such comments will provoke from some of my colleagues. Others I hope will equally be able to see the potential ‘writing on the wall’. What I will finish by saying though is that, whatever is in store, I do confidently predict some sort of radical New Order for nurse education in the medium-term future.
References Barr, H., 2002. Interprofessional Education Today, Yesterday and Tomorrow. Learning and Teaching Support Network for Health Sciences and Practice, London. Birchenall, P., 2000. Nurse education in the year 2000: reflection, speculation and challenge. Nurse Education Today 20, 1–2. Cooper, K., Harrison, S., 2003. NHS university forced to change name to . . . NHSU. Nursing Standard 18 (4), 7. Deans, C., Congdon, G., Sellers, E.T., 2003. Nurse education in English universities in a period of change: expectations of nurse academics for the year 2008. Nurse Education Today 23, 146–154. Fairley, D., 2003. Nurse Consultants as higher level practitioners: factors perceived to influence role, implementation and development in critical care. Intensive and Critical Care Nursing 19, 198–206. Francis, B., Humphreys, J., 1998. The commissioning of nurse education by consortia in England: a quasi-market analysis. Journal of Advanced Nursing 28, 517–523. Glen, S., Clark, A., 1999. Nurse education: a skill mix for the future. Nurse Education Today 19, 12–19. Glen, S., 2002. Practice/academic career pathways in the health and social care professions. Learning in Health and Social Care 1, 59–62. Guest, C., Smith, L., Bradshaw, M., Hardcastle, W., 2002. Facilitating interprofessional learning for medical and nursing students in clinical practice. Learning in Health and Social Care 1, 132–138. Horsburgh, M., Lamdin, R., Williamson, E., 2001. Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. Medical Education 35, 876–883. Inglis, T., 2003. Nurse Anesthetists: one step forward, one step back: physician supervision requirements for CRNA’s jeopardize access to care. American Journal of Nursing 103, 91–94. Mcilfatrick, S., 2004. The future of nurse education: characterised by paradoxes. Nurse Education Today 24, 79–83. Morison, S., Boohan, M., Jenkins, J., Moutray, M., 2003. Facilitating undergraduate interprofessional learning in healthcare: comparing classroom and clinical learning for nursing and medical students. Learning in Health and Social Care 2, 92–104. Mulholland, H., 2003. Academics fear the NHSU has sights on nurse education. Nursing Times 99 (37), 8.
254 Wharrad, H., Clifford, C., Horsburgh, M., Ketefian, S., Lee, J., 2002. Global network explores diversity and opportunity in nurse education. Nurse Education Today 22, 15–23. Whitehead, D., 2003. The health-promoting nurse as a health policy career expert and entrepreneur. Nurse Education Today 23, 585–592.
Guest editorial Dean Whitehead Massey University, School of Health Sciences College of Humanities and Social Sciences Palmerston North New Zealand
Nurse Education Today intl.elsevierhealth.com/journals/nedt
GUEST EDITORIAL
Nurse education in the future: Will one size fit all?
Trying to second-guess what the future holds for nurse education has been a major pre-occupation for nursing over many decades. More recently, articles of this nature have tended to look at the short-term future effects of legislated policy and reform – thus the degree of accuracy has been quite marked when it comes to evaluating these speculations a few years down the line (i.e., Francis and Humphreys, 1998; Glen and Clark, 1999; Mcilfatrick, 2004). In this editorial, I propose a ‘leap of faith’ that projects the reader 10–20 years on, thus presenting a personal prediction of what nurse education (if we will still be calling it this) might look like then. As with any rhetorical muse, however, there can be no substance without an element of factual basis and so I present my speculations, where possible, against a current factual context. I will start with my most controversial prediction. Firstly, I predict that there will be no ‘specific’ nursing education in the medium-term future. In my mind, health professions or multiprofessional education will be the norm – at least in Western curricula and certainly within Higher Education institutions. You do not have to be a crystal-ball gazer though to see this one coming. At my previous university, proposals were in place some time ago to replace all ‘nursing-specific’ programmes with generic health professions modules that are open to all health care professional groups. Related discussions proposed a shared pre-qualifying one-year ‘common foundation programme’ for nursing and medical students. An all-graduate entry requirement for health professional groups, and the pre-requisite of continuing post-qualifying education, will further drive this situation (Birchenall, 2000).
0260-6917/$ - see front matter c 2005 Published by Elsevier Ltd. doi:10.1016/j.nedt.2005.04.001
Collaborative health professions education is already with us to varying degrees, with combined and shared pre- and post-qualifying programmes for medical and dentistry students, nurses and other professions allied to medicine (in some countries abbreviated to PAMs) in place for some (Horsburgh et al., 2001; Guest et al., 2002; Barr, 2002; Wharrad et al., 2002; Morison et al., 2003). No matter how daunting this change might appear, however, it does not represent a huge swing in direction for nursing education, other than in terms of the rationalisation, funding and administration of such programmes. Medical and PAM-related education programmes broadly share similar content and operate within similar structural frameworks i.e., the medical model. Alongside this, the blurring of health professions’ roles (discussed later) suggests, to me, a progressive symbiosis of all health care-orientated education into health professions education. I will also add here a further consideration in that I believe inter-professional health education will have to face up to aligning its curricula towards accepting non-health care staff and students into its midst. The acceptance of students from all walks of public life i.e., social, charitable, voluntary and business backgrounds and institutions, who do not necessarily want to become registered health practitioners but are interested in aspects of health service provision, is likely at some point. Many universities are being forced to rationalise educational programmes whereby modules and papers are essentially repeated many times in institutions, often unknowingly, by different departments and different lecturers. I argue that where this particularly needs to happen is within health care professional-orientated programmes.
252 It is unsustainable for universities to offer separate nursing, medicine, dietetic, physiotherapy, occupational therapy, podiatry, etc., programmes (administered and delivered by separate academic staff) within single institutions. What makes this situation particularly unsustainable is the blurring of discipline-specific roles and responsibilities between health professional groups and an obvious overlap of knowledge and skills (Wharrad et al., 2002). In a number of countries, and especially in the UK, a number of factors have been at play over recent years to produce this effect. Increasing lay and user involvement in determining health service policy provision, quality-based broad health service reform, the increasing amount of ‘celebrated’ medical malpractice, the advent of evidence-based collaborative practice and the rationalisation of doctors and nurses hours and roles, have all forced inevitable changes in the working practices of health care professional groups. Doctors are legislating for less working hours against the fact that they are becoming more socially accountable, as the profession has its ‘traditional’ practices publicly scrutinised. Subsequently, nurses are the natural successors to take on the responsibilities that medicine is wishing to, or is being forced to, discharge. Nurses are increasingly expected to take on a more biotechnical role through extended practices – thus producing a blurring of medical and nursing roles. Role titles, such as Consultant Nurse are already mirroring this fact and, similarly, issues centred on the role of Nurse Anaesthetists prevail (Fairley, 2003; Inglis, 2003). I predict that as health professional disciplines evolve further, this will eventually reflect a position where there is no significant difference between the role of a doctor and a nurse. Administrators, of both Higher Education and health service institutions will welcome this, in that such blurring of roles will raise the question – ‘why pay doctors far more than other health professional groups if their roles are similar?’ Picture if you will then, a single health care-orientated curriculum that delivers to both groups and all other health professional groups in the process. In fact, add the evolving roles of nurses and doctors together and we may have the eventual demise of both professions in their current form! Taking the above-mentioned situations further, what will career pathways look like for health professionals in the medium-term future? Generally, nurse education currently delivers a foundation course that is followed up by a ‘branch-specific’ discipline speciality. Following
Guest editorial registration, nurses can then specialise further in their chosen clinical discipline by undertaking post-qualifying programmes of study and/or clinical competence. I predict that this will change. As the role of applied medicine adapts to take on a broader and more holistic remit, such as complementary medicine, I predict that there will be less emphasis on specialised bio-clinically focused attributes. Competing against inevitable rationalisation agendas, current roles and responsibilities will be further undermined as health services seek to produce a ‘generic’ better-for-value health practitioner. Perhaps there will be a generic foundation programme for all health care professionals, which will then allow its students to choose a speciality branch on successful completion of the foundation requirements. Not a clinical discipline-specific branch though I hasten to add. Instead, the health care professional may choose their branch according to the career pathway that they want to pursue – which could be management, administration, research, academia, education, policy development, etc. Universities may even offer a curriculum that fits all of these aspects into health professions training as the main themes within a foundation programme. I have already argued the case, in NET, for a specific career route that develops the nurse as a career health policy-maker (Whitehead, 2003). Glen (2002) has also put forward the case for the marrying of health and social care professions in pursuing an academic career pathway. As well as the issue of what will happen to nursing students of the future, there also remains the question of what will become of nurse lecturers/academics. My belief is that, as much as nursing students will disappear, so too will nurse educators – at least in the Higher Education setting. Deans et al.’s (2003) study suggests that universities, if they actually want to, will have problems in the future recruiting suitably qualified or experienced nurse academics as they struggle with the dilemmas of fewer departments of nursing, static academic status, conflicting role obligations (i.e., clinical and scholarly) and economic rationalisation agendas. In line with predicted generic health professions curricula, however, there will be no need for nursing-specific lecturers. Existing nurse lecturers will presumably have to ally themselves to other disciplines as they seek to specialise in non-nursing-specific areas and, perhaps, align themselves to broader social and clinical-science-based careers. Glen and Clark (1999) have identified that the generalist role of the nurse educator has already been eroded by ‘highly qualified specialists’.
Guest editorial Barr (2002) identifies shifts in inter-professional education that have led to a move away from profession-specific lecturers towards generalists, as higher education managers seek to rationalise programmes and gain economies of scale. Therefore, nurse educators will either have to adapt to developing themselves as highly qualified ‘nonnursing specialists’ or see themselves replaced. In my field of public health and health promotion, I am more and more involved with non-nurses than I am with nurses. Sometimes this is imposed by evolving agendas, while other times it is actually in my best interests to actively pursue this course of action. I am sad to say that, on occasions, it has been necessary for me to distance myself from nursing in order to fulfill my required role. I do believe that there will still be a place for ‘traditional’ nurse lecturers, although not in the Higher Education setting. Nurse lecturers must pursue academic credibility in the Higher Education arena or be left behind (Glen and Clark, 1999). As things begin to come full circle in nursing education, I predict a return to nursingspecific programmes being delivered purely in the clinical setting for non-registered nurses. Perhaps here, against this type of scenario, we might again witness the return of the clinical nurse tutor role. Already, many universities are beginning to ‘farm out’ their nursing-based modules, papers and programmes to clinically based partnerships. I favour this, as in my mind, the best place to deliver clinically focused programmes is in the clinical setting and delivered by those who are most clinically credible – active clinical practitioners. In the UK, the advent of the National Health Service University (NHSU) looked set to speed up this process and possibly take university-based nurse education away from the universities (Mulholland, 2003; Cooper and Harrison, 2003), but recently its role and future, if any, has become much more blurred. In the mean time, as nursing education aligns itself more closely with medical education and other health professional groups, nursing students will need to become far more conversant with independent learning strategies that will see them using more and more technology and health informatics-based teaching, virtual instruction (web-based portal and conferencing interventions), virtual laboratories for skills learning and various e-learning strategies (Wharrad et al., 2002). All of the above-mentioned situations, I believe, will set a precedent for the way that nurse education will be delivered in the future. New scopes for educational delivery will further speed up the requirements for new mind-sets,
253 new ways of delivering education, a new type of lecturer/academic and a new type of clinical workforce. So, I predict lots of radical change for nurse education and I predict its eventual demise over the next 20 years or so. I know that such a prediction will have me waving in the wind and I can also envisage the degree of consternation that such comments will provoke from some of my colleagues. Others I hope will equally be able to see the potential ‘writing on the wall’. What I will finish by saying though is that, whatever is in store, I do confidently predict some sort of radical New Order for nurse education in the medium-term future.
References Barr, H., 2002. Interprofessional Education Today, Yesterday and Tomorrow. Learning and Teaching Support Network for Health Sciences and Practice, London. Birchenall, P., 2000. Nurse education in the year 2000: reflection, speculation and challenge. Nurse Education Today 20, 1–2. Cooper, K., Harrison, S., 2003. NHS university forced to change name to . . . NHSU. Nursing Standard 18 (4), 7. Deans, C., Congdon, G., Sellers, E.T., 2003. Nurse education in English universities in a period of change: expectations of nurse academics for the year 2008. Nurse Education Today 23, 146–154. Fairley, D., 2003. Nurse Consultants as higher level practitioners: factors perceived to influence role, implementation and development in critical care. Intensive and Critical Care Nursing 19, 198–206. Francis, B., Humphreys, J., 1998. The commissioning of nurse education by consortia in England: a quasi-market analysis. Journal of Advanced Nursing 28, 517–523. Glen, S., Clark, A., 1999. Nurse education: a skill mix for the future. Nurse Education Today 19, 12–19. Glen, S., 2002. Practice/academic career pathways in the health and social care professions. Learning in Health and Social Care 1, 59–62. Guest, C., Smith, L., Bradshaw, M., Hardcastle, W., 2002. Facilitating interprofessional learning for medical and nursing students in clinical practice. Learning in Health and Social Care 1, 132–138. Horsburgh, M., Lamdin, R., Williamson, E., 2001. Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. Medical Education 35, 876–883. Inglis, T., 2003. Nurse Anesthetists: one step forward, one step back: physician supervision requirements for CRNA’s jeopardize access to care. American Journal of Nursing 103, 91–94. Mcilfatrick, S., 2004. The future of nurse education: characterised by paradoxes. Nurse Education Today 24, 79–83. Morison, S., Boohan, M., Jenkins, J., Moutray, M., 2003. Facilitating undergraduate interprofessional learning in healthcare: comparing classroom and clinical learning for nursing and medical students. Learning in Health and Social Care 2, 92–104. Mulholland, H., 2003. Academics fear the NHSU has sights on nurse education. Nursing Times 99 (37), 8.
254 Wharrad, H., Clifford, C., Horsburgh, M., Ketefian, S., Lee, J., 2002. Global network explores diversity and opportunity in nurse education. Nurse Education Today 22, 15–23. Whitehead, D., 2003. The health-promoting nurse as a health policy career expert and entrepreneur. Nurse Education Today 23, 585–592.
Guest editorial Dean Whitehead Massey University, School of Health Sciences College of Humanities and Social Sciences Palmerston North New Zealand