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Nursing education: Key issues for the 21st century
Nurse Education Today (2006) 26, 614–621
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing education: Key issues for the 21st century q Sally E. Thorne
*
University of British Columbia, School of Nursing, T201-2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 19 July 2006
KEYWORDS
Summary In this paper, I reflect on what can be learned by engaging in future thinking within our discipline, and what implications the results of that thinking may have for the development of nursing education. Recognizing the marvelous diversity of perspective within our discipline with regard to what will and ought to be our future mandate, it seems reasonable to search for some grounding in what might ensure that we enter that future wisely. We all know that change is a fundamental characteristic of all future projections, and yet that insight seems a weak justification for failure to plan. Nurse educators hold a particular obligation to ensure that they are preparing the professionals who will take that future forward. Although we have always recognized that they must nurse for today with an eye on tomorrow, it is inordinately difficult to come to some agreement on how we can best bridge that gap within our educational programs and strategies. Toward this end, I draw on lessons that can be drawn from our professional history as a rich and vibrant context to propose some key issues for that future theorizing. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 614–621 and Nurse Education in Practice Vol. 6, No. 6, pp. 306–313.
Nursing education; Trends; Nursing profession; History of nursing
Introduction The world of future thinking in nursing is a strange one. Reading through the marvelous diversity of q Initially presented as a keynote lecture at the Nursing Education Today/Nursing Education in Practice First International Nursing Education Conference, May 14–16, Vancouver BC. * Tel.: +1 604 822 7748; fax: +1 604 822 7423. E-mail address: [email protected].
imaginal projections that are contained within our futuristic literature, one gets the sense of science fiction run wild in the minds of our theorists and practice dreamers. While exhortations of virtual nursing, holographic patients, and interplanetary health research may seem naively fanciful (Bunkers, 2000; Huch, 1995; Parse, 1991; Spitzer, 1998), they also invoke within us a sense that stretching our minds into improbable possibilities is something we must learn if we are to enter that
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
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future wisely. We intuitively understand that looking beyond what we can immediately grasp becomes an imperative if we are to withstand the forces of change and cling on to what we in nursing hold most dear. And we recognize that whatever our trepidations, that future will still unfold with its own commanding trajectory. We who carry the torch for nursing education hold a particular responsibility for our part in this future thinking. Our core business is the preparation of the next generation of nurses so that they might take their rightful place in a world order that we can only begin to comprehend. We craft knowledge frameworks, conceptualizations, and theoretical structures so that an infinite set of new ideas will arise out of the mist and take shape in the world of nursing practice. In this paper, I argue that what guides us is not simply our capacity to project the details of that future but rather, more importantly, to learn from our past. Drawing on our philosophical foundations, the values and ideals upon which this nursing profession is grounded, we find substance that can help us reflect upon what and who we are, and how we might carry that ontological essence into the future. In this context, I propose what I consider to be key issues for nursing education as we embark upon the coming century – key issues for all of us to grapple with in our quest for ensuring that the core values inherent in nursing of the past find purchase within the dizzying possibilities of our collective future.
corporate structures have been undergoing unprecedented upheaval, and social institutions such as the university are exploring new mechanisms for relevance and accountability. Within our various health care systems, there have been massive global shifts in professional autonomy, public engagement, and system redesign (Romanow, 2002). With our colleagues across the full range of health disciplines and social policy sectors, we have begun to realise that 10% of the world’s health problems receive 90% of the world’s health resources and that this is no longer defensible (Global Forum for Health Research, 2004). Our tolerance for a have/have not world is rapidly shifting as we realise the inherent and immediate global impact of economic inequities on such shared problems as epidemics. There has also been a corresponding reflexivity within academic medicine that seems unprecedented within our lifetime. The International Campaign to Revitalize Academic Medicine (ICRAM) Project (Tugwell, 2004) involves stakeholders representing academia, business and industry, government and policy makers, journal editors, patients, professional associations, students and trainees. Operating through a core working party of 20 medical academics representing 14 countries, its explicit mandates are to (1) redefine the core values of and contribute to the evidence basis for academic medicine; (2) develop strategy around reformed academic medicine, and (3) stimulate a public debate on the future (International Working Party to Promote and Revitalise Academic Medicine, 2004). Toward those ends, the project has generated scenarios depicting what the world might look like and how academic medicine might move forward toward leadership rather than reactivity (Clark, 2005). Among the observations arising from analysis of the common features of these scenarios are the suggestions that: academic medicine will have to put more effort into relating to its stakeholders; that it will also have to become more globally minded; that while teamwork will be increasingly important, individuals will also have to shine and to flourish; that teaching, researching, improving, leading and providing service will continue to be important, but expecting individuals to be equally competent in them will be recognized as increasingly impractical; that competition among academic institutions is likely to increase; and that academic institutions will need to become increasingly businesslike and more adept at using media (paraphrased from Clark, 2005). In highlighting what our colleagues in academic medicine consider the real imperatives, these observations reflect many of the issues about which academic nursing should also be profoundly concerned.
A time for reflection A century change is a natural and important time for reflection and reconsideration. With half of the millennium’s first decade now past, we recall with humour how frightening it was when we made that transition from 1999 to 2000, sure that all of our computer-based society would fall apart with the digital adjustment, and also worried that, having lived all our time in years beginning with the digits one and nine, that we would not know how to feel this new millennium. Having now found our way into it, we discover that in most aspects it is not all that different from the decade that went before. We still struggle with the same health care reform issues, still worry about impending nursing shortages, and still battle with the same funding agencies to consider nursing educational scholarship a viable form of research. Coincident with this same millennium transition, we have seen considerable reflective reinvention within many of society’s institutions (Inayatullah and Gidley, 2000). National governments have been rapidly cycling from left to right and back again,
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A time for dialogue The occasion of the First International Conference on Nursing Education (NETNEP 2006), in which hundreds of passionately committed nurse educators gathered to charge up their batteries, seemed a fitting time to catalyze a new focus within our collective dialogue in hopes that it would continue within our scholarly literature. The key issues articulated by conference planners foreshadowed much of this priority setting, articulating such foci as: inter-professional education; research, evidence based practice, and technology in health and education; and service user involvement in the way we educate health care professionals. The enthusiasm with which conference participants engaged in sharing their stories, listening to the experience of others, and reflecting upon their commonalities and diversities fuelled a sense of excitement that nurse educators have considerable power to shape an exciting future. Given the privilege of speaking in the conference’s opening session, I took the opportunity to enter this dialogue by structuring my comments around the dialectic between nursing knowledge and nursing action, recognizing that this is the intersection within which so much of our nursing educational analysis resides. I took as my starting points what I believe to be shared foundational assumptions regarding our core business in nursing education if our discipline is to continue to serve its fundamental mandate of preserving and supporting the health of populations. For me, these are a knowledgeable nursing workforce and a viable professional voice.
A knowledgeable nursing workforce We who have taken up the mantle of nursing education believe to our core that the health of a society is shaped by the degree to which it can develop and sustain a knowledgeable nursing workforce. However, what this meant historically and what it is coming to mean are changing. We need to find ways to shift this forward without leaving behind what is precious. As various nurse scholars have recognized, nursing has historically been caught at the level of ‘‘the patient’’ (and we know total patient care better than any other). In the current world, we are going to have to find ways to preserve that commitment without it becoming our limitation. The paradox, as we have realised, is that if we allow our collective gaze to remain entirely at the level of that individual, we cannot make a dis-
S.E. Thorne ciplinary contribution to the social policy issues that ultimately have far more impact on that individual’s overall likelihood of health and well-being than our individual care can secure. I believe that our success in building a knowledgeable nursing workforce of the future will depend on our coming to some agreement on a balanced combination of what they will need to know and also how they will need to know it. In the following discussion, I propose a few of the areas in which we could use some thoughtful reflection and dialogue.
Pragmatics In the future, the knowledge we bring to bear to develop nursing practice will have to include a very large dose of practicality. From all indications, it seems clear that that which will be funded as our global health care systems evolve is that which can be economically justifiable. Nurses, being entrenched into a service ethic and committed to care regardless of economic context have an inordinately difficult time adjusting their sights to include that economic argument. And yet, because we know that this is an essential ingredient in generating effective programs and services for the future, we must learn how to include something of it within our core curricula. We will also need to create a generation of nurses who can move beyond the intuitive ‘‘knowing’’ that their ministrations make a difference toward grappling with the complexities of measurable ‘‘nurse-sensitive outcomes’’. In order to do so, we will need to continue to take leadership in methodological innovations to permit research integration and synthesis, to combine methods so that complex ideas can be considered in context, and so that those who control the resources can begin to understand the implications of systems of nursing at the population level. Toward this end, we will need to find ways to move beyond some of our individual ‘‘positioning’’ in the sense of what constitutes a ‘‘right’’ approach, and our convictions as to which theoretical perspective ought to dominate. In order for nursing do really do what it has always set out to do, to retain a focus on the full spectrum of human experience in health and illness, we must find ways to prepare the next generation of nurses to be as competent and comfortable in the language of pathophysiology and molecular biology as feel they are in the discourse of spirituality and holism. Not only will we have to educate the new generation toward competence and confidence, but we will
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also have to ensure that it comes well prepared with humility; each of these fields is enormous, vast, and complex, and oversimplifying them would ultimately disserve us in meeting those objectives. We must not only remain credible to ourselves, but to an increasingly sophisticated and critical audience of interprofessional team members, public policy decision-makers, and health care consumers. So that delicate balance between confidence in what we do know and reverence for what we do not and cannot know will have to be a hallmark of that knowledgeable nursing workforce of the future.
more highly acute all the time. Instead, many nurses will necessarily be shifting attention toward the burden of chronic illness, whether we encounter it in hospitals, ambulatory clinics, or in communities. And this shift will not simply involve a new orientation to skillsets, but also to undoing those structures and processes we have put into place because the assumptions inherent in acuity (patient passivity, professional expertise and so on) have become part of the problem in chronic illness care. We will also be increasingly learning to work with unregulated care workers, coping with new pressures such as the generic ‘‘Health Care Worker’’ that has cropped up in some jurisdictions, and working more effectively with the meaningful human social groupings that we historically related to as if they were all ‘‘nuclear families’’.
Evidence One prominent aspect of disciplinary knowledge in which we will need to steer a radical shift has to do with what it means to make claims related to evidence-based practice. The language of evidence will increasingly shape policy and resource allocation, and so we need to be collectively conversant with it and to have a strong cadre of our membership who speak that language fluently. In particular, we need to move, quite quickly, beyond our current conceptualization that we have done justice to this concept by teaching nurses to read a research paper. That specific element is like the well-known Sufi Parable of the Blind Born – teaching nurses to privilege a single angle of vision on a particular problem, often without really knowing that there are multiple angles that ought to be considered in order to understand the nature of the phenomenon we are attempting to engage with. What the knowledgeable nursing workforce will demand is a more collective capacity to understand and collaborate with research integration and synthesis processes in order to begin to work those distinctive perspectives into a more integrated whole. And that kind of analysis will not be happening at the front line of nursing or at the neophyte scholar level, but more collectively within our specialty groupings and substantive academic communities. It will be work that we – none of us – can do independently, and we must learn to do it as a discipline.
Local context Another shift needed in this new world is from the orientation of knowing how-to-do and moving toward the skills associated with how-to-ensure-itis-done. We know that there will be fewer nurses focusing their everyday practice on high acuity – although it is of course important and getting even
Global context We are also fully aware that nursing education can no longer afford to prepare practitioners for highly specialized local settings to meet immediate workforce needs. We all know that nurses will move around, that settings will change even if they do not, and so we must prepare for a global world and a world of complexity. More importantly within this context, we need to shift our attention from training nurses who primarily think about local conditions toward educating practitioners who have the ‘‘big picture thinking’’ that allows them to ‘‘think globally’’. This new generation will have to face the mobility of the world, and the interconnectedness that entails. For example, no longer will it be reasonable to consider certain diseases to only exits ‘‘there’’ because ‘‘there is now here’’. Beyond the practical reasons that this is becoming an imperative, there are moral imperatives pointing us toward recognition that this is the ‘‘right’’ thing to be doing. Taking up those moral challenges, we want to shift our attention from thinking of nurses as being good corporate citizens to thinking of them as being exemplary ‘‘global citizens’’. We need to wrestle with such challenges as how to nurture a service ethic within a ‘‘me first’’ generation. We need to learn how to prepare nurses who have a fully embedded sense of the economic implications of health and illness, of what causes ill health, of what drives health service, and of what sustainable impacts they can envision. And we need to create strategies to guide nurses who will work effectively within an increasing diversity of worldviews and perspectives.
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Diversity We recognize that there are very few homogenous societies in today’s world – and that a standard of basic entry level practice competency in nursing is to know how to work thoughtfully and as equitably as possible with diversity. This includes people who relate differently to what we offer, and people for whom health and illness and our role in relation to them are understood differently. This process has caused us to reflect more seriously on the fact that we as a discipline also hold a shared world view – that we represent a particular perspective on matters of illness and healing, and that we must recognize and understand the implications of that perspective. We need to be able to distinguish between the beliefs and values we hold by virtue of our disciplinary allegiance and those facts and truth claims we draw upon in order to justify what we do and how we do it.
Complexity In order to accomplish all of this, it seems evident that we cannot any longer afford to accept uncritically held and superficial attachments to binary dimensions like issues of right and wrong, good and evil. The nurses of the future will have to be able to simultaneously hold in their minds ideas that are apparently contradictory – the patient as confronting death and at the same time hoping for miracles, the seriously ill person who is managing well and also not coping at all, the patient as autonomous being and the family as being the primary locus of that patient’s decision making. We have for too long tolerated conceptualizations that polarize possibilities – compliance and non-compliance, normalization and disability, health and illness, hope and despair as by definition mutually exclusive entities. In order to move forward in this world, the nurses of the future have to be able to recognize, but think beyond the conceptual categorizations with which we educate them. They will have to understand that uncertainty and certainty co-exist, that the patient who manages self-care independently is also dependent, that the person who is overwhelmed with fear is also grounded in courage. They will learn to work with patients in a sensitive and nuanced manner that respects and reaches out to all of the contradictory parts of their experience. This kind of thinking will force us out of our standardized diagnostic approaches, our simplistic conceptualization models, and into new and more excitingly complex ways of organizing and shaping our understandings.
S.E. Thorne If these requirements for a truly knowledgeable nursing workforce of the future are any indication, there are obvious and considerable implications for nursing education. As a hospitaltrained RN who only reluctantly returned to school to earn a degree (never knowing how far that path would lead!), I have had the luxury of seeing a significant shift in how we do business in nursing education, and am therefore confident we can do it again. For example, I believe that we need the capacity to shift what we currently do from both a curricular and a pedagogical perspective and extend beyond our ‘motherhood’ claims about such phenomena as holism – which is individualism in context – and to figure out how better to work and teach across the individual, family, community and societal continuum. We need to know how to think bio-psycho-social to population-based and back again, and do to that in a dynamic and rapid-cycling intellectual process, not on separate days and in separate times. From my perspective, this capacity is and will be the unique contribution of nursing, and we need to ensure that it is effectively learned in the foundational stages if we are to survive as a profession into this challenging future. Remember, across the planet, as we become more educated and more expensive, we also become more expendable unless we know how to translate our inner conviction that nursing matters into an objective, defensible, business case that clearly documents the value that a knowledgeable nursing workforce brings to a healthy society. So this ‘‘knowing’’ will have to move beyond subjectivities and individual patient care to include a much different kind of justification and evidence. In short, we need to move from belief to defensible convictions, from assumptions to objectively verifiable claims. And it is these which will make that future nursing workforce genuinely knowledgeable.
A viable professional voice The second major issue that I think defines what we all believe we are aiming for is a viable professional ‘‘voice’’. In this changing context, if nursing is to remain professionally viable, we need not only to prepare a new generation of nurses with a changing body of knowledge and knowing, but also to provide them with the structural scaffolding within which this knowledge and knowing can be enacted. The following are what I would consider the foundations of that scaffolding.
Nursing education: Key issues for the 21st century
Workplace organization Globally, the workplace of nursing is shifting and under predictable strain. We cannot any longer ‘‘do nursing’’ in the older ways. This is not that unlike the challenge facing our common ancestor, Florence Nightingale, in formalizing the training required for nursing practice, or the later revolution in turning the bulk of nursing from homes into hospitals. One can only imagine the challenge of shifting from untrained to trained, from one-to-one convalescent care to a more orderly and organized way of delivering nursing service to larger groups of patients. Now it seems that we need to be working within and across settings, with populations not units, and ensuring that we keep our sights on what the contribution of nursing is and ought to be within that changing interprofessional context. Defending the old ways would not work, and reacting after the fact to the changes that others decide on our behalf is notoriously unsatisfying.
Leadership and power We also need to ‘‘train up’’ a new generation not to consider their professional leaders as having joined the ‘‘dark side’’ but in fact as being the best allies they can hope for at the level of system wide decision-making. Large scale resource allocation and policy revision will always seem set against individual patient care. There is no policy change in the world for which a good nurse cannot imagine someone being negatively affected. However, we need a new generation of nurses capable of avoiding getting caught up in the passivity and victim mentality characterized by the assumption that bad decisions will always be made and nurses have no power to influence them. Nursing is a large and powerful professional occupational group, and has tremendous power; however, we need to learn collectively how to use that power as a social force – to work more closely together as an influence toward social change, to find the places at which we can speak with one voice, and to support each other from our different angles of vision in so doing.
Complexity and vision This changing context will also require an increasing number of nurses prepared at the master’s and doctoral levels. We need this because we need individuals within our midst who are prepared to deconstruct the ideological claims that are sometimes made on our behalf and to help nurses see
619 alternative ways of understanding the world. We need to move beyond collectively indulging in some of what can characteristically seem like disciplinary knee-jerk reactions and to discover ways of being within the world that will enhance our public and political credibility and capacity. We also need to learn collectively to grapple with the really hard questions that will influence how we do nursing in the future and could potentially influence the way the public learns to think about health and health care priorities. For example, can we find ways to challenge the uncritically held assumptions that our societies hold about right action, and to surface the uncomfortable truths that reveal our collective values? Why is it, for example, that the appropriateness is rarely challenged of rescuing conjoint twins from a small village in Africa, bringing the family to North America for a year or more until the surgical correction is complete, and then sending them all back into an uncertain environment? Does that appease our collective sense that we privileged folk in the West have helped the less fortunate of the world? Or should nursing be capable of balancing that kind of act with a vociferous demand for the reallocation of those resources so that antiretroviral and anti-malarial medications might be provided for an entire region? You can see by the example that I have chosen here – a difficult example I know – that I firmly believe this tension between individual and population will characterize the moral leadership that nursing of the future is capable of enacting.
Interdisciplinarity Clearly, we also must prepare nurses for an increasingly complex and inherently interdisciplinary health care team, one that will extend beyond the medical and allied health professionals that we are only now beginning to acknowledge in our nursing curricula, to include kinds of professional and non-professional groups that we have not conventionally considered as health care workers. These will include unregulated workers, generic ‘‘taskoriented’’ providers, and also members of those public sectors who have not traditionally been considered part of ‘‘health’’, such as education, public works, the legal system, and housing.
Collectivity And in this world of complexity, diversity, and interdisciplinarity, we must also figure out how to prepare nurses capable of retaining that capacity
620 for a common vision that we all hold dear. We work in such different ways, with such different kinds of problems. And yet, as those of us who are privileged to be in the classroom with diverse groups of specialized nurses who come together for the purpose of graduate education appreciate, there is a fundamental and powerful core connection between us all that has a lot to do with where we came from and how we got there. That shared understanding of the body, of the body in the human context, of the experience, of the nurse–patient relationship, of the infinite capacity for human variation, and of the translation from the general to the particular – these cannot be lost as we shape our nursing workforce into the future or we may risk losing the power of that collective vision of what it means to be a nurse. And that collective vision – no matter how tricky it is and has always been to define it – is the essence of what we are. As we move forward toward ensuring this viable professional voice, we will grapple with a number of tough questions. How can we educate nurses toward the capacity for a common vision? How can we help them balance surface self-advocacy with coming together toward future thinking and creating a leading a force for service to society? How can we help them sustain the passion for nursing within workplace contexts that are likely to be increasingly challenging? We all know that our governments are facing shortages, and that employers want ‘‘job ready’’ graduates. So how can we look beyond simply getting them ready for this context and ensure that we are providing them with what it will take to stick with it and to thrive in this kind of practice world, and then ultimately to be its next change agents? How can we prepare nurses who retain their core essence despite an increasing diversity of practice contexts, settings, and foci – nurses who will continue to recognize one another ‘‘as nurses’’? And how can we reformulate our theories and conceptualizations so that they are better suited to the social, economic and political realities of the world in which this future nursing will occur? It seems to me that we need to work collaboratively between the nursing education and service leadership community to advance the contributions of the discipline to the fundamental challenge of health system reform. And because of this, the skillset that is needed to be a really effective nurse educator will also shift so that we are all equally comfortable in drawing knowledge from books and bedsides, and we all know how to work effectively within the academy and the health authority. After all, that is what our historic leaders understood – that linkage between hospital administra-
S.E. Thorne tion and the running of nursing schools, that integration of the passion of apprenticeship and mentorship, of creating workplace environments in which the wisdom of the seasoned practitioner could interact with the idealism of the neophyte.
Aligning knowledge and action in nursing education Fundamentally, then, it seems apparent that our ideas and our action vision will have to inform one another in a new form of nursing educational praxis. While it may not be a major stretch to teach about a model of praxis, we know that by far the best approach is to learn to model it. In order to move toward this capacity, we need to discover what the nursing professorate must learn to shift its knowledge and rapidly engage with the newer ideas. It seems evident that we cannot simply wait for a generation to change; rather, we will have to develop a scholarship around how to support new ideas, strategies and ways of thinking within nursing education itself. Conferences such as the International Nursing Education Conference (NETNEP) held in Vancouver in 2006 are an excellent beginning. We know that excitement about nursing knowledge is infectious, and it seems that we ought to try to capitalize on what we know about how infectious processes spread most rapidly to really catalyze significant change; we can ensure that we spread our enthusiasm with high doses, friendly vectors, and multiple exposures. While the complexity of nursing necessitates that none of us can do it all and that we must diversify our foci, it also seems that we cannot afford a nursing education community in which a significant number of us do only teaching, and not practice, professional service or research. Rather, a hallmark of continuing competence within teaching should include a sustained relevance within a range of these activities. Thus we must increasingly find creative ways to blend various combinations of those dimensions – so that our students are exposed to excellent practitioners, that the knowledge development we ascribe to does not only get translated into practice but also taken up in education. I believe that we need to work aggressively toward a culture of engagement, and a broad base of what we consider scholarship that includes educational scholarship in all of its diversity (Boyer, 1990; Riley et al., 2002; Storch and Gamroth, 2002). Nurse educators are not simply nurses who have mastered practice sufficiently to oversee the learning of neophyte practitioners, or those who have taken a graduate degree within the disci-
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pline, but rather they are professional experts with a substantive body of knowledge related to the complexities inherent in creating learning contexts, guiding intellectual journeys, and igniting a passion for what this profession embodies in its essence. We therefore have an obligation to attend seriously to the scholarship of teaching within all of its diversity, to ensure that it has equivalent stature with clinical research as a disciplinary and academic priority for nursing.
part must be in shaping this future. We are not leaving the past; we are merely bringing it with us into this exciting new world.
Concluding thoughts In a brief commentary such as this, a deep and thoughtful analysis of any of these complex issues is impossible. What I have instead intended is a tantalizing overview of the wide scope of angles from which I think we must collectively approach this 21st century, and some hints of strategies toward which we might marshal our collective imagination. In so doing, I attempt to set the stage for the truly creative, innovative, and impassioned educational scholarship that nurse educators share when they do find the occasion to gather together. It is in these conversations that the deep analysis, the insightful innovation, and the genuine leadership emerge. As has emerged in academic medicine, I do believe that an ‘‘International Campaign to Revitalize Academic Nursing’’ would make excellent sense as we navigate the way forward over the coming years. And so I encourage my colleagues in nursing education to take up that challenge. From my perspective, there is no greater profession in the world than nursing, and no greater privilege than to be involved in nurturing the next generation of nurses. As we embark on this 21st century, we have such a marvelous base of history, of tradition, and of knowledge upon which to build, and we can enter the new complexities fully grounded with an understanding of why we are here and what our
References Boyer, E.L., 1990. Scholarship Revisited: Priorities of the Professoriate. The Carnegie Foundation for the Advancement of Teaching, Princeton, NJ. Bunkers, S.S., 2000. Nurse scholar of the 21st century. Nursing Science Quarterly 113, 116–123. Clark, J., 2005. Five futures for academic medicine: the ICRAM scenarios. British Medical Journal 331, 101–104. Global Forum for Health Research, 2004. 10/90 Report on health research, 2003–2004. Available from:. Huch, M.H., 1995. Nursing and the next millennium. Nursing Science Quarterly 8 (1), 38–44. Inayatullah, S., Gidley, J., 2000. The University in Transformation: Global Perspectives on the Futures of the University. Bergin & Garvey, Westport CT. International Working Party to Promote and Revitalise Academic Medicine, 2004. ICRAM (the International Campaign to Revitalise Academic Medicine): agenda setting. British Medical Journal 329, 787–789. Available from: . Parse, R.R., 1991. Nursing knowledge for the 21st century: an international commitment. Nursing Science Quarterly 5 (1), 8–12. Riley, J.M., Beal, J., Levi, P., McCausland, M.P., 2002. Revisioning nursing scholarship. Journal of Nursing Scholarship 34 (4), 383–389. Romanow, R.J., 2002. Building on values: the future of health care in Canada – Final report of the Commission on the Future of Health Care in Canada. Canadian Government, Ottawa. Available from: . Spitzer, A., 1998. Nursing in the health care system of the postmodern world: crossroads, paradoxes and complexity. Journal of Advanced Nursing 28, 164–171. Storch, J., Gamroth, L., 2002. Scholarship revisited: a collaborative nursing education program’s journey. Journal of Nursing Education 41 (12), 524–530. Tugwell, P., 2004. Editorial: Campaign to revitalise academic medicine kicks off. British Medical Journal 328, 597. Available from: .
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Nursing education: Key issues for the 21st century q Sally E. Thorne
*
University of British Columbia, School of Nursing, T201-2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5 Accepted 19 July 2006
KEYWORDS
Summary In this paper, I reflect on what can be learned by engaging in future thinking within our discipline, and what implications the results of that thinking may have for the development of nursing education. Recognizing the marvelous diversity of perspective within our discipline with regard to what will and ought to be our future mandate, it seems reasonable to search for some grounding in what might ensure that we enter that future wisely. We all know that change is a fundamental characteristic of all future projections, and yet that insight seems a weak justification for failure to plan. Nurse educators hold a particular obligation to ensure that they are preparing the professionals who will take that future forward. Although we have always recognized that they must nurse for today with an eye on tomorrow, it is inordinately difficult to come to some agreement on how we can best bridge that gap within our educational programs and strategies. Toward this end, I draw on lessons that can be drawn from our professional history as a rich and vibrant context to propose some key issues for that future theorizing. c 2006 Elsevier Ltd. All rights reserved. This article appears in a joint issue of the journals Nurse Education Today Vol. 26, No. 8, pp. 614–621 and Nurse Education in Practice Vol. 6, No. 6, pp. 306–313.
Nursing education; Trends; Nursing profession; History of nursing
Introduction The world of future thinking in nursing is a strange one. Reading through the marvelous diversity of q Initially presented as a keynote lecture at the Nursing Education Today/Nursing Education in Practice First International Nursing Education Conference, May 14–16, Vancouver BC. * Tel.: +1 604 822 7748; fax: +1 604 822 7423. E-mail address: [email protected].
imaginal projections that are contained within our futuristic literature, one gets the sense of science fiction run wild in the minds of our theorists and practice dreamers. While exhortations of virtual nursing, holographic patients, and interplanetary health research may seem naively fanciful (Bunkers, 2000; Huch, 1995; Parse, 1991; Spitzer, 1998), they also invoke within us a sense that stretching our minds into improbable possibilities is something we must learn if we are to enter that
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved.
Nursing education: Key issues for the 21st century
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future wisely. We intuitively understand that looking beyond what we can immediately grasp becomes an imperative if we are to withstand the forces of change and cling on to what we in nursing hold most dear. And we recognize that whatever our trepidations, that future will still unfold with its own commanding trajectory. We who carry the torch for nursing education hold a particular responsibility for our part in this future thinking. Our core business is the preparation of the next generation of nurses so that they might take their rightful place in a world order that we can only begin to comprehend. We craft knowledge frameworks, conceptualizations, and theoretical structures so that an infinite set of new ideas will arise out of the mist and take shape in the world of nursing practice. In this paper, I argue that what guides us is not simply our capacity to project the details of that future but rather, more importantly, to learn from our past. Drawing on our philosophical foundations, the values and ideals upon which this nursing profession is grounded, we find substance that can help us reflect upon what and who we are, and how we might carry that ontological essence into the future. In this context, I propose what I consider to be key issues for nursing education as we embark upon the coming century – key issues for all of us to grapple with in our quest for ensuring that the core values inherent in nursing of the past find purchase within the dizzying possibilities of our collective future.
corporate structures have been undergoing unprecedented upheaval, and social institutions such as the university are exploring new mechanisms for relevance and accountability. Within our various health care systems, there have been massive global shifts in professional autonomy, public engagement, and system redesign (Romanow, 2002). With our colleagues across the full range of health disciplines and social policy sectors, we have begun to realise that 10% of the world’s health problems receive 90% of the world’s health resources and that this is no longer defensible (Global Forum for Health Research, 2004). Our tolerance for a have/have not world is rapidly shifting as we realise the inherent and immediate global impact of economic inequities on such shared problems as epidemics. There has also been a corresponding reflexivity within academic medicine that seems unprecedented within our lifetime. The International Campaign to Revitalize Academic Medicine (ICRAM) Project (Tugwell, 2004) involves stakeholders representing academia, business and industry, government and policy makers, journal editors, patients, professional associations, students and trainees. Operating through a core working party of 20 medical academics representing 14 countries, its explicit mandates are to (1) redefine the core values of and contribute to the evidence basis for academic medicine; (2) develop strategy around reformed academic medicine, and (3) stimulate a public debate on the future (International Working Party to Promote and Revitalise Academic Medicine, 2004). Toward those ends, the project has generated scenarios depicting what the world might look like and how academic medicine might move forward toward leadership rather than reactivity (Clark, 2005). Among the observations arising from analysis of the common features of these scenarios are the suggestions that: academic medicine will have to put more effort into relating to its stakeholders; that it will also have to become more globally minded; that while teamwork will be increasingly important, individuals will also have to shine and to flourish; that teaching, researching, improving, leading and providing service will continue to be important, but expecting individuals to be equally competent in them will be recognized as increasingly impractical; that competition among academic institutions is likely to increase; and that academic institutions will need to become increasingly businesslike and more adept at using media (paraphrased from Clark, 2005). In highlighting what our colleagues in academic medicine consider the real imperatives, these observations reflect many of the issues about which academic nursing should also be profoundly concerned.
A time for reflection A century change is a natural and important time for reflection and reconsideration. With half of the millennium’s first decade now past, we recall with humour how frightening it was when we made that transition from 1999 to 2000, sure that all of our computer-based society would fall apart with the digital adjustment, and also worried that, having lived all our time in years beginning with the digits one and nine, that we would not know how to feel this new millennium. Having now found our way into it, we discover that in most aspects it is not all that different from the decade that went before. We still struggle with the same health care reform issues, still worry about impending nursing shortages, and still battle with the same funding agencies to consider nursing educational scholarship a viable form of research. Coincident with this same millennium transition, we have seen considerable reflective reinvention within many of society’s institutions (Inayatullah and Gidley, 2000). National governments have been rapidly cycling from left to right and back again,
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A time for dialogue The occasion of the First International Conference on Nursing Education (NETNEP 2006), in which hundreds of passionately committed nurse educators gathered to charge up their batteries, seemed a fitting time to catalyze a new focus within our collective dialogue in hopes that it would continue within our scholarly literature. The key issues articulated by conference planners foreshadowed much of this priority setting, articulating such foci as: inter-professional education; research, evidence based practice, and technology in health and education; and service user involvement in the way we educate health care professionals. The enthusiasm with which conference participants engaged in sharing their stories, listening to the experience of others, and reflecting upon their commonalities and diversities fuelled a sense of excitement that nurse educators have considerable power to shape an exciting future. Given the privilege of speaking in the conference’s opening session, I took the opportunity to enter this dialogue by structuring my comments around the dialectic between nursing knowledge and nursing action, recognizing that this is the intersection within which so much of our nursing educational analysis resides. I took as my starting points what I believe to be shared foundational assumptions regarding our core business in nursing education if our discipline is to continue to serve its fundamental mandate of preserving and supporting the health of populations. For me, these are a knowledgeable nursing workforce and a viable professional voice.
A knowledgeable nursing workforce We who have taken up the mantle of nursing education believe to our core that the health of a society is shaped by the degree to which it can develop and sustain a knowledgeable nursing workforce. However, what this meant historically and what it is coming to mean are changing. We need to find ways to shift this forward without leaving behind what is precious. As various nurse scholars have recognized, nursing has historically been caught at the level of ‘‘the patient’’ (and we know total patient care better than any other). In the current world, we are going to have to find ways to preserve that commitment without it becoming our limitation. The paradox, as we have realised, is that if we allow our collective gaze to remain entirely at the level of that individual, we cannot make a dis-
S.E. Thorne ciplinary contribution to the social policy issues that ultimately have far more impact on that individual’s overall likelihood of health and well-being than our individual care can secure. I believe that our success in building a knowledgeable nursing workforce of the future will depend on our coming to some agreement on a balanced combination of what they will need to know and also how they will need to know it. In the following discussion, I propose a few of the areas in which we could use some thoughtful reflection and dialogue.
Pragmatics In the future, the knowledge we bring to bear to develop nursing practice will have to include a very large dose of practicality. From all indications, it seems clear that that which will be funded as our global health care systems evolve is that which can be economically justifiable. Nurses, being entrenched into a service ethic and committed to care regardless of economic context have an inordinately difficult time adjusting their sights to include that economic argument. And yet, because we know that this is an essential ingredient in generating effective programs and services for the future, we must learn how to include something of it within our core curricula. We will also need to create a generation of nurses who can move beyond the intuitive ‘‘knowing’’ that their ministrations make a difference toward grappling with the complexities of measurable ‘‘nurse-sensitive outcomes’’. In order to do so, we will need to continue to take leadership in methodological innovations to permit research integration and synthesis, to combine methods so that complex ideas can be considered in context, and so that those who control the resources can begin to understand the implications of systems of nursing at the population level. Toward this end, we will need to find ways to move beyond some of our individual ‘‘positioning’’ in the sense of what constitutes a ‘‘right’’ approach, and our convictions as to which theoretical perspective ought to dominate. In order for nursing do really do what it has always set out to do, to retain a focus on the full spectrum of human experience in health and illness, we must find ways to prepare the next generation of nurses to be as competent and comfortable in the language of pathophysiology and molecular biology as feel they are in the discourse of spirituality and holism. Not only will we have to educate the new generation toward competence and confidence, but we will
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also have to ensure that it comes well prepared with humility; each of these fields is enormous, vast, and complex, and oversimplifying them would ultimately disserve us in meeting those objectives. We must not only remain credible to ourselves, but to an increasingly sophisticated and critical audience of interprofessional team members, public policy decision-makers, and health care consumers. So that delicate balance between confidence in what we do know and reverence for what we do not and cannot know will have to be a hallmark of that knowledgeable nursing workforce of the future.
more highly acute all the time. Instead, many nurses will necessarily be shifting attention toward the burden of chronic illness, whether we encounter it in hospitals, ambulatory clinics, or in communities. And this shift will not simply involve a new orientation to skillsets, but also to undoing those structures and processes we have put into place because the assumptions inherent in acuity (patient passivity, professional expertise and so on) have become part of the problem in chronic illness care. We will also be increasingly learning to work with unregulated care workers, coping with new pressures such as the generic ‘‘Health Care Worker’’ that has cropped up in some jurisdictions, and working more effectively with the meaningful human social groupings that we historically related to as if they were all ‘‘nuclear families’’.
Evidence One prominent aspect of disciplinary knowledge in which we will need to steer a radical shift has to do with what it means to make claims related to evidence-based practice. The language of evidence will increasingly shape policy and resource allocation, and so we need to be collectively conversant with it and to have a strong cadre of our membership who speak that language fluently. In particular, we need to move, quite quickly, beyond our current conceptualization that we have done justice to this concept by teaching nurses to read a research paper. That specific element is like the well-known Sufi Parable of the Blind Born – teaching nurses to privilege a single angle of vision on a particular problem, often without really knowing that there are multiple angles that ought to be considered in order to understand the nature of the phenomenon we are attempting to engage with. What the knowledgeable nursing workforce will demand is a more collective capacity to understand and collaborate with research integration and synthesis processes in order to begin to work those distinctive perspectives into a more integrated whole. And that kind of analysis will not be happening at the front line of nursing or at the neophyte scholar level, but more collectively within our specialty groupings and substantive academic communities. It will be work that we – none of us – can do independently, and we must learn to do it as a discipline.
Local context Another shift needed in this new world is from the orientation of knowing how-to-do and moving toward the skills associated with how-to-ensure-itis-done. We know that there will be fewer nurses focusing their everyday practice on high acuity – although it is of course important and getting even
Global context We are also fully aware that nursing education can no longer afford to prepare practitioners for highly specialized local settings to meet immediate workforce needs. We all know that nurses will move around, that settings will change even if they do not, and so we must prepare for a global world and a world of complexity. More importantly within this context, we need to shift our attention from training nurses who primarily think about local conditions toward educating practitioners who have the ‘‘big picture thinking’’ that allows them to ‘‘think globally’’. This new generation will have to face the mobility of the world, and the interconnectedness that entails. For example, no longer will it be reasonable to consider certain diseases to only exits ‘‘there’’ because ‘‘there is now here’’. Beyond the practical reasons that this is becoming an imperative, there are moral imperatives pointing us toward recognition that this is the ‘‘right’’ thing to be doing. Taking up those moral challenges, we want to shift our attention from thinking of nurses as being good corporate citizens to thinking of them as being exemplary ‘‘global citizens’’. We need to wrestle with such challenges as how to nurture a service ethic within a ‘‘me first’’ generation. We need to learn how to prepare nurses who have a fully embedded sense of the economic implications of health and illness, of what causes ill health, of what drives health service, and of what sustainable impacts they can envision. And we need to create strategies to guide nurses who will work effectively within an increasing diversity of worldviews and perspectives.
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Diversity We recognize that there are very few homogenous societies in today’s world – and that a standard of basic entry level practice competency in nursing is to know how to work thoughtfully and as equitably as possible with diversity. This includes people who relate differently to what we offer, and people for whom health and illness and our role in relation to them are understood differently. This process has caused us to reflect more seriously on the fact that we as a discipline also hold a shared world view – that we represent a particular perspective on matters of illness and healing, and that we must recognize and understand the implications of that perspective. We need to be able to distinguish between the beliefs and values we hold by virtue of our disciplinary allegiance and those facts and truth claims we draw upon in order to justify what we do and how we do it.
Complexity In order to accomplish all of this, it seems evident that we cannot any longer afford to accept uncritically held and superficial attachments to binary dimensions like issues of right and wrong, good and evil. The nurses of the future will have to be able to simultaneously hold in their minds ideas that are apparently contradictory – the patient as confronting death and at the same time hoping for miracles, the seriously ill person who is managing well and also not coping at all, the patient as autonomous being and the family as being the primary locus of that patient’s decision making. We have for too long tolerated conceptualizations that polarize possibilities – compliance and non-compliance, normalization and disability, health and illness, hope and despair as by definition mutually exclusive entities. In order to move forward in this world, the nurses of the future have to be able to recognize, but think beyond the conceptual categorizations with which we educate them. They will have to understand that uncertainty and certainty co-exist, that the patient who manages self-care independently is also dependent, that the person who is overwhelmed with fear is also grounded in courage. They will learn to work with patients in a sensitive and nuanced manner that respects and reaches out to all of the contradictory parts of their experience. This kind of thinking will force us out of our standardized diagnostic approaches, our simplistic conceptualization models, and into new and more excitingly complex ways of organizing and shaping our understandings.
S.E. Thorne If these requirements for a truly knowledgeable nursing workforce of the future are any indication, there are obvious and considerable implications for nursing education. As a hospitaltrained RN who only reluctantly returned to school to earn a degree (never knowing how far that path would lead!), I have had the luxury of seeing a significant shift in how we do business in nursing education, and am therefore confident we can do it again. For example, I believe that we need the capacity to shift what we currently do from both a curricular and a pedagogical perspective and extend beyond our ‘motherhood’ claims about such phenomena as holism – which is individualism in context – and to figure out how better to work and teach across the individual, family, community and societal continuum. We need to know how to think bio-psycho-social to population-based and back again, and do to that in a dynamic and rapid-cycling intellectual process, not on separate days and in separate times. From my perspective, this capacity is and will be the unique contribution of nursing, and we need to ensure that it is effectively learned in the foundational stages if we are to survive as a profession into this challenging future. Remember, across the planet, as we become more educated and more expensive, we also become more expendable unless we know how to translate our inner conviction that nursing matters into an objective, defensible, business case that clearly documents the value that a knowledgeable nursing workforce brings to a healthy society. So this ‘‘knowing’’ will have to move beyond subjectivities and individual patient care to include a much different kind of justification and evidence. In short, we need to move from belief to defensible convictions, from assumptions to objectively verifiable claims. And it is these which will make that future nursing workforce genuinely knowledgeable.
A viable professional voice The second major issue that I think defines what we all believe we are aiming for is a viable professional ‘‘voice’’. In this changing context, if nursing is to remain professionally viable, we need not only to prepare a new generation of nurses with a changing body of knowledge and knowing, but also to provide them with the structural scaffolding within which this knowledge and knowing can be enacted. The following are what I would consider the foundations of that scaffolding.
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Workplace organization Globally, the workplace of nursing is shifting and under predictable strain. We cannot any longer ‘‘do nursing’’ in the older ways. This is not that unlike the challenge facing our common ancestor, Florence Nightingale, in formalizing the training required for nursing practice, or the later revolution in turning the bulk of nursing from homes into hospitals. One can only imagine the challenge of shifting from untrained to trained, from one-to-one convalescent care to a more orderly and organized way of delivering nursing service to larger groups of patients. Now it seems that we need to be working within and across settings, with populations not units, and ensuring that we keep our sights on what the contribution of nursing is and ought to be within that changing interprofessional context. Defending the old ways would not work, and reacting after the fact to the changes that others decide on our behalf is notoriously unsatisfying.
Leadership and power We also need to ‘‘train up’’ a new generation not to consider their professional leaders as having joined the ‘‘dark side’’ but in fact as being the best allies they can hope for at the level of system wide decision-making. Large scale resource allocation and policy revision will always seem set against individual patient care. There is no policy change in the world for which a good nurse cannot imagine someone being negatively affected. However, we need a new generation of nurses capable of avoiding getting caught up in the passivity and victim mentality characterized by the assumption that bad decisions will always be made and nurses have no power to influence them. Nursing is a large and powerful professional occupational group, and has tremendous power; however, we need to learn collectively how to use that power as a social force – to work more closely together as an influence toward social change, to find the places at which we can speak with one voice, and to support each other from our different angles of vision in so doing.
Complexity and vision This changing context will also require an increasing number of nurses prepared at the master’s and doctoral levels. We need this because we need individuals within our midst who are prepared to deconstruct the ideological claims that are sometimes made on our behalf and to help nurses see
619 alternative ways of understanding the world. We need to move beyond collectively indulging in some of what can characteristically seem like disciplinary knee-jerk reactions and to discover ways of being within the world that will enhance our public and political credibility and capacity. We also need to learn collectively to grapple with the really hard questions that will influence how we do nursing in the future and could potentially influence the way the public learns to think about health and health care priorities. For example, can we find ways to challenge the uncritically held assumptions that our societies hold about right action, and to surface the uncomfortable truths that reveal our collective values? Why is it, for example, that the appropriateness is rarely challenged of rescuing conjoint twins from a small village in Africa, bringing the family to North America for a year or more until the surgical correction is complete, and then sending them all back into an uncertain environment? Does that appease our collective sense that we privileged folk in the West have helped the less fortunate of the world? Or should nursing be capable of balancing that kind of act with a vociferous demand for the reallocation of those resources so that antiretroviral and anti-malarial medications might be provided for an entire region? You can see by the example that I have chosen here – a difficult example I know – that I firmly believe this tension between individual and population will characterize the moral leadership that nursing of the future is capable of enacting.
Interdisciplinarity Clearly, we also must prepare nurses for an increasingly complex and inherently interdisciplinary health care team, one that will extend beyond the medical and allied health professionals that we are only now beginning to acknowledge in our nursing curricula, to include kinds of professional and non-professional groups that we have not conventionally considered as health care workers. These will include unregulated workers, generic ‘‘taskoriented’’ providers, and also members of those public sectors who have not traditionally been considered part of ‘‘health’’, such as education, public works, the legal system, and housing.
Collectivity And in this world of complexity, diversity, and interdisciplinarity, we must also figure out how to prepare nurses capable of retaining that capacity
620 for a common vision that we all hold dear. We work in such different ways, with such different kinds of problems. And yet, as those of us who are privileged to be in the classroom with diverse groups of specialized nurses who come together for the purpose of graduate education appreciate, there is a fundamental and powerful core connection between us all that has a lot to do with where we came from and how we got there. That shared understanding of the body, of the body in the human context, of the experience, of the nurse–patient relationship, of the infinite capacity for human variation, and of the translation from the general to the particular – these cannot be lost as we shape our nursing workforce into the future or we may risk losing the power of that collective vision of what it means to be a nurse. And that collective vision – no matter how tricky it is and has always been to define it – is the essence of what we are. As we move forward toward ensuring this viable professional voice, we will grapple with a number of tough questions. How can we educate nurses toward the capacity for a common vision? How can we help them balance surface self-advocacy with coming together toward future thinking and creating a leading a force for service to society? How can we help them sustain the passion for nursing within workplace contexts that are likely to be increasingly challenging? We all know that our governments are facing shortages, and that employers want ‘‘job ready’’ graduates. So how can we look beyond simply getting them ready for this context and ensure that we are providing them with what it will take to stick with it and to thrive in this kind of practice world, and then ultimately to be its next change agents? How can we prepare nurses who retain their core essence despite an increasing diversity of practice contexts, settings, and foci – nurses who will continue to recognize one another ‘‘as nurses’’? And how can we reformulate our theories and conceptualizations so that they are better suited to the social, economic and political realities of the world in which this future nursing will occur? It seems to me that we need to work collaboratively between the nursing education and service leadership community to advance the contributions of the discipline to the fundamental challenge of health system reform. And because of this, the skillset that is needed to be a really effective nurse educator will also shift so that we are all equally comfortable in drawing knowledge from books and bedsides, and we all know how to work effectively within the academy and the health authority. After all, that is what our historic leaders understood – that linkage between hospital administra-
S.E. Thorne tion and the running of nursing schools, that integration of the passion of apprenticeship and mentorship, of creating workplace environments in which the wisdom of the seasoned practitioner could interact with the idealism of the neophyte.
Aligning knowledge and action in nursing education Fundamentally, then, it seems apparent that our ideas and our action vision will have to inform one another in a new form of nursing educational praxis. While it may not be a major stretch to teach about a model of praxis, we know that by far the best approach is to learn to model it. In order to move toward this capacity, we need to discover what the nursing professorate must learn to shift its knowledge and rapidly engage with the newer ideas. It seems evident that we cannot simply wait for a generation to change; rather, we will have to develop a scholarship around how to support new ideas, strategies and ways of thinking within nursing education itself. Conferences such as the International Nursing Education Conference (NETNEP) held in Vancouver in 2006 are an excellent beginning. We know that excitement about nursing knowledge is infectious, and it seems that we ought to try to capitalize on what we know about how infectious processes spread most rapidly to really catalyze significant change; we can ensure that we spread our enthusiasm with high doses, friendly vectors, and multiple exposures. While the complexity of nursing necessitates that none of us can do it all and that we must diversify our foci, it also seems that we cannot afford a nursing education community in which a significant number of us do only teaching, and not practice, professional service or research. Rather, a hallmark of continuing competence within teaching should include a sustained relevance within a range of these activities. Thus we must increasingly find creative ways to blend various combinations of those dimensions – so that our students are exposed to excellent practitioners, that the knowledge development we ascribe to does not only get translated into practice but also taken up in education. I believe that we need to work aggressively toward a culture of engagement, and a broad base of what we consider scholarship that includes educational scholarship in all of its diversity (Boyer, 1990; Riley et al., 2002; Storch and Gamroth, 2002). Nurse educators are not simply nurses who have mastered practice sufficiently to oversee the learning of neophyte practitioners, or those who have taken a graduate degree within the disci-
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pline, but rather they are professional experts with a substantive body of knowledge related to the complexities inherent in creating learning contexts, guiding intellectual journeys, and igniting a passion for what this profession embodies in its essence. We therefore have an obligation to attend seriously to the scholarship of teaching within all of its diversity, to ensure that it has equivalent stature with clinical research as a disciplinary and academic priority for nursing.
part must be in shaping this future. We are not leaving the past; we are merely bringing it with us into this exciting new world.
Concluding thoughts In a brief commentary such as this, a deep and thoughtful analysis of any of these complex issues is impossible. What I have instead intended is a tantalizing overview of the wide scope of angles from which I think we must collectively approach this 21st century, and some hints of strategies toward which we might marshal our collective imagination. In so doing, I attempt to set the stage for the truly creative, innovative, and impassioned educational scholarship that nurse educators share when they do find the occasion to gather together. It is in these conversations that the deep analysis, the insightful innovation, and the genuine leadership emerge. As has emerged in academic medicine, I do believe that an ‘‘International Campaign to Revitalize Academic Nursing’’ would make excellent sense as we navigate the way forward over the coming years. And so I encourage my colleagues in nursing education to take up that challenge. From my perspective, there is no greater profession in the world than nursing, and no greater privilege than to be involved in nurturing the next generation of nurses. As we embark on this 21st century, we have such a marvelous base of history, of tradition, and of knowledge upon which to build, and we can enter the new complexities fully grounded with an understanding of why we are here and what our
References Boyer, E.L., 1990. Scholarship Revisited: Priorities of the Professoriate. The Carnegie Foundation for the Advancement of Teaching, Princeton, NJ. Bunkers, S.S., 2000. Nurse scholar of the 21st century. Nursing Science Quarterly 113, 116–123. Clark, J., 2005. Five futures for academic medicine: the ICRAM scenarios. British Medical Journal 331, 101–104. Global Forum for Health Research, 2004. 10/90 Report on health research, 2003–2004. Available from: