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Position Statement: To meet the challenges
of Nursing's Agenda for Health Care Reform, the federal
initiatives Healthy People 2000 and Healthy People
2010, and evolutions in health care delivery, faculty
in schools of nursing must re-examine their missions of education,
research, and service. Nursing leaders in education and practice
settings must work together to differentiate the roles and
responsibilities of nurses in practice.
Preparation for the entry-level professional
nurse now requires a greater orientation to community-based
primary health care, and an emphasis on health promotion,
maintenance and cost-effective coordinated care that responds
to the needs of culturally diverse groups and underserved
and other populations in all settings. Advanced nursing practice
requires graduate preparation, which may focus on primary
health care, case management, community health, specialization,
education, or administration across health care settings.
Nursing research must move to an emphasis
on individual, family and community-level interventions and
outcomes. This will require more researchers who have advanced
preparation in nursing, a solid foundation in nursing practice,
knowledge from a variety of disciplines, and ability to use
a wide range of methodologies.
To achieve the level of competence
required of graduates to meet the challenges of health care
for the 21st century, schools of nursing must redefine the
scholarship role and reward system for faculty to include
practice, teaching, research, and integration of these roles.
Schools should seek opportunities to provide direct-care services
as a means of integrating the missions of education, research,
and service.
A. Introduction and Background
This American Association of Colleges
of Nursing (AACN) position statement delineates a suggested
role for nursing education in the context of Nursing's Agenda
for Health Care Reform, the goals of Healthy People 2000 and
Healthy People 2010, and evolutions in health care delivery.
These three documents as well as numerous other proposals
indicate that major changes in access to health care will
occur through expanded coverage. Nursing's Agenda for Health
Care Reform emphasizes increased access and better health
care for broad segments of the population through primary
health care delivery and emphasis on disease prevention and
health promotion. Establishing a variety of health care alternatives
will help reduce costs by allowing the client to choose high-quality
appropriate services (American Nurses Association, 1991).
The federal initiatives Healthy People 2000 and Healthy People
2010 have set goals in many specific areas, including health
promotion, disease prevention, screening, and immunizations.
Because the challenge of improving the nation's health is
an interdisciplinary one, nursing education must anticipate
and prepare for these changes in order to educate its students
for this new environment.
The concerns over today's health care
system result from high costs, limited access, and issues
of quality. In 1997, 41 million Americans under age 65 were
without health insurance (National Center for Health Statistics,
1999). The present situation will worsen as the American population
ages and requires more attention to health-related concerns.
Indeed, Americans are living longer, to an average age of
75 years. By 2030, an estimated 20 percent of Americans will
be 65 or more years old (National Center for Health Statistics,
1999).
Another concern is the high incidence
of many avoidable conditions and chronic diseases. Since the
late 1980s, the incidence of low- birthweight babies has contributed
to an infant mortality rate of approximately 10 deaths for
every 1,000 live births. Federal figures from 1995 and 1998
estimate that 32 million Americans have arthritis, 8 million
have diabetes, and 23 percent of Americans age 20-74 suffer
from hypertension (National Center for Health Statistics,
1995, 1998). In addition, 27 percent of the population smokes,
51 percent drink alcohol, and 5 percent of Americans age 12
and older have reported using illicit drugs during the previous
month (National Center for Health Statistics, 1999). These
last figures are particularly alarming because public funds
bear half of the cost for alcohol and drug abuse treatment
(The Robert Wood Johnson Foundation, 1991).
Culturally diverse populations traditionally
have had less access to preventive health care than the majority
population. This results in an increase in the complexity
and cost of interventions when treatment begins in the later
stages of a disease or chronic condition. The largest minority
group (12 percent), African Americans, have a shorter life
expectancy than the overall population (69.4 years vs. 75
years). African and Hispanic Americans are at higher risk
than European Americans for the five leading causes of death:
heart disease, cancer, stroke, injuries, and homicide (U.S.
Department of Health and Human Services, 1991).
To meet the many demands in the health
care system, there has been a movement of health care providers
from more acute-care settings to community-, work-, and school-based
healthcare centers as well as nurse-managed centers. The many
changes in the health care system are affecting nursing education.
This is reflected in the number of schools of nursing that
are establishing faculty practice plans and nursing centers.
In 1998, 119 schools operated campus- or community-based nursing
centers (American Association of Colleges of Nursing, 1998).
Nursing education faces a major challenge
in addressing the persistent decline in baccalaureate nursing
education program enrollments that began in 1995. At the same
time, master's and doctoral enrollments are enjoying modest
growth. (American Association of Colleges of Nursing, 1999)
Several factors are relevant to this condition. Baccalaureate
and graduate nursing education programs have had difficulty
in attracting qualified faculty for both didactic and clinical
education. Among the reasons for this are budgetary constraints,
competition with clinical service agencies, and lack of qualified
applicants in the area. Insufficient classroom space and a
scarcity of clinical training sites, highly sought after due
to the emphasis on community-based services, also are challenges
for nursing educators. Baccalaureate nursing education programs
have had a good record of enrolling minority students and
continue to make gains in this area, but graduation rates
for minority students continue to fall below those for white
students. Advanced-degree programs have been less successful
in this area. If the profession of nursing is to more closely
reflect the ethnicity of future patient populations, this
situation also will require further attention.
The future demand for nurses had been
projected to exceed availability even before the decline in
undergraduate enrollments began. Federal data estimate that
rising demand will outstrip the supply of registered nurses
beginning approximately in 2010. By 2015, 114,000 jobs for
full-time equivalent RNs are expected to go unfilled nationwide
(National Advisory Council on Nurse Education and Practice,
1996). All areas of health care, especially hospitals, health
maintenance organizations, primary care centers, home care,
nursing homes, outpatient surgical centers, schools, work
sites, and community health clinics, will need nurses. In
addition, nurses with graduate-degree education are taking
their places as advanced-practice clinicians in acute-care
and community settings, as well as in health promotion, and
are filling other needed roles in administration, teaching,
and research.
This position statement outlines approaches
for schools of nursing to use in meeting the health care system's
future need for nurses educated at baccalaureate, master's,
and doctoral levels. Nursing education must plan its evolution
to address developments in health care delivery, nursing practice,
research outcomes, and new technologies. Nursing research
underpins effective nursing education and practice. Professional
nurses must become aware of the importance of these interrelationships.
B. Guidelines for Schools of
Nursing
Mission
The mission statement of each school
requires comprehensive review and evaluation for relevance
to local, regional, national, and global future health care
needs. In revision of the school's mission statement, the
school should consider not only the broad ways in which its
programs address health care needs, but also unique contributions
of the school in relation to its resources and setting. The
mission statement should embody a sense of today's health
care issues, but must tie this to a vision of future health
care and the consideration of preparing students to address
the unknown and unforeseen.
- The mission statement should be distinctive.
It should address the school's unique or special contributions
drawn from the strengths of the institution in which it
is imbedded and the needs and opportunities of the community
it serves.
- The mission statement should indicate
clearly the ways in which the school is linked to and serves
a particular community or communities, whether local, regional,
national, or global.
- The mission statement should clearly
address the school's service purposes, including its role
in the delivery of health care.
Organizational Structure
The structure of the school should allow
for and facilitate flexibility in the development of new initiatives
and programs. The school should use data from on-going evaluation
of its processes and outcomes, including cost/benefit analyses,
as a basis for organizational change.
The organizational structure of the school
should reflect the missions of teaching, research, community
service, and practice. The structure should foster linkages
among these four areas and between the school and its external
environment.
- The organizational structure should
recognize, support and reward nursing excellence in teaching,
research, community service, and nursing practice.
- The school should have clearly-defined
organizational mechanisms through which to consider, critique
and act on new ideas.
- The organizational structure should
ensure linkages with other disciplines. These should move
beyond traditional collaboration among the health disciplines
to include interdisciplinary teaching, research, practice,
and service in areas such as the humanities, arts and social
and natural sciences.
Faculty
Since nursing is a practice profession,
faculty should have opportunities to maintain clinical practice
and be rewarded for the contribution of practice to faculty
excellence. Nursing educators must base their teaching in
the reality of active practice to prepare nurses for future
reformation in the health care environment (Hegyvary, 1992).
Faculty need to serve as competent role models that reflect
"the knowledge, skills, and attitudes of the practitioner
for 2005", and the educational system must recognize and highly
regard their competency (Shugars et al, 1991).
- In addition to research, teaching
and service, practice should be included in promotion and
tenure criteria.
- The significance of practice and the
responsibility to conduct practice-relevant research should
be communicated to other disciplines in the academic realm
(Rodgers, 1986).
- Nursing faculty should reaffirm the
need for pedagogical research in the learning environment.
The AACN objective to "advance the
goals of nursing practice, education, and research" (AACN,
1990) via collaborative arrangements between clinical
facilities and nursing schools incorporates initiatives
for faculty practice and clinical preceptorship that could
substantially alter the process of nursing education.
Initiatives for faculty practice may require increased
flexibility in clinical assignments and practice settings.
Faculty practice should be viewed as scholarship and integrated
within the faculty role. In this way it provides a vehicle
for achieving the goals of Healthy People 2000
and Healthy People 2010.
- A strategic plan should evolve from
institutional goals to assure professional competency of
all faculty.
- Opportunities for practice should
emphasize community-based centers as well as include traditional
hospital and long-term care settings.
- Faculty practice programs should encompass
the economic aspects of the environment for which they are
intended.
- Nursing educators should generate
and produce cost-effective quality health care in collaboration
with community-based affiliates.
- Clear delineation of goals for both
nursing education and nursing practice should provide for
measurement of outcomes towards a healthier America.
- In order to initiate faculty practice,
a nursing program should:
- evaluate financial and clinical
resources
- assess faculty position differentiations
and workload, including contract limitations
- clarify values and define priorities
with related goals
- attain community and administrative
support
Strategies to accommodate faculty practice
may include:
- clinical educator faculty appointments
(Fagin, 1987)
- joint appointments (Joel, 1985)
- group faculty practice (Joel, 1985)
- released-time assignment systems with
faculty receiving pay from the clinical setting (McClure,
1987)
- proportional distribution of faculty
lines for people competent in practice as well as theory
development (McClure, 1987)
- use of non-traditional settings [eg.
day-care/Head Start] for practice and student experience
(Free & Mills, 1985)
- alliances with other joint services
and university units such as physical therapy, social work,
occupational therapy, and medicine to offer collaborative
practice opportunities (Langford, 1987).
Students
The nursing profession and schools of
nursing must recruit and retain students who reflect the diversity
of the client population they will serve. Currently, members
of the nursing profession are predominantly white, middle-class
women. Yet, the population of the United States is increasing
in ethnic and cultural diversity. Many at-risk populations
come from specific ethnic groups. To deliver effective health
care, the nursing population should be representative of these
groups, show sensitivity to cultural differences, communicate
in the same language, and understand the value systems of
their clients as related to health status and health care.
(Hegyvary, 1992)
The nursing profession and schools of
nursing must use effective and creative recruitment strategies
to achieve cultural diversity.
- To send the message to potential students
that the profession embraces diversity and fosters success
in a valued career, ethnically diverse nurses should actively
participate in recruitment programs.
- Advertisements should use current
mass communication techniques that target specific populations.
- Information about nursing should be
available in elementary, middle, and high school populations
where demographics are rapidly changing.
- Recruitment efforts should provide
information on career ladder opportunities for culturally
diverse groups that are underrepresented in nursing.
- Recruiters should increase gender
and educational background representation in nursing by
seeking college graduates in other fields and displaced
employees (eg. from industry, agriculture) who are interested
in alternate career opportunities.
- Nurse educators representing programs
that prepare nursing personnel at all levels should develop
articulation agreements to facilitate career ladder opportunities.
- Nurse educators and nursing service
administrators should collaborate in developing opportunities
for career mobility for personnel.
The retention of culturally diverse students
in schools of nursing is a primary goal in meeting the nation's
health care agenda (U.S.Department of Health and Human Services,
1991).
- Schools of nursing should create a
culturally sensitive, supportive learning environment for
students.
- Schools of nursing should provide
opportunities for faculty to acquire cultural sensitivity
to diverse groups.
- Financial support should be available
for students who come from economically and socially disadvantaged
backgrounds.
- English-as-Second-Language students
should have support to facilitate their mastery of the curriculum.
- Faculty should establish informal
networks with students to provide role modeling, learning
strategies, and personal support.
- Educators should carefully monitor
and nurture students as they progress through the program.
Curricula
Nursing education is occurring within
the context of rapidly changing technologies and dramatically
expanding knowledge. Students must learn to acquire, apply,
and evaluate new knowledge. Therefore, curricular processes
and outcomes should be emphasized as well as curricular content
in preparing nurses for meaningful roles in future health
care systems.
Curricular processes involve the teaching-learning
interchange and include such important aspects as role modeling,
collaborative problem-solving and professional socialization.
These processes are of critical importance in the student's
development of the following essential cognitive and interpersonal
abilities:
- critical thinking
- ethical decision-making
- information seeking, sorting and selection
- establishing and maintaining nurse-client
relationships
- therapeutic communication, including
teaching and advocacy
- design, management, and coordination
of care
- interdisciplinary team participation
- sensitivity to socioeconomic, religious,
lifestyle, and cultural diversity
- critical self-assessment
In addition to content that addresses
nursing's role in the provision of high-quality care for the
acutely ill, the following broad content areas are recommended
because of their relevance to the development of healthy life
styles and to future health care problems and solutions:
- health promotion and maintenance in
relation to:
- chronic conditions such as cardiovascular
disease, cancer and mental illness
- infectious diseases, particularly
HIV infection, sexually transmitted diseases and tuberculosis
- acute conditions such as accidental
injuries/trauma
- health promotion with particular emphasis
on:
- nutrition
- family planning
- maternal-infant health
- substance abuse prevention
- mental health
- environmental and occupational
health
- geriatric health
- prevention of family and social
violence
- economics and health care
- cost factors
- cost-benefit assessment
- reimbursement issues
- ethical and legal principles
- political and social action strategies
- socioeconomic factors affecting health
- information and health care technologies
Differentiation of nursing roles and
responsibilities, based on educational preparation, is necessary
for efficient and effective health care delivery. Nursing
personnel, prepared to function as assistants or technicians
under the supervision of professional nurses, should perform
procedures and tasks associated with client care and the care
environment.
Professional nurses are prepared through
baccalaureate, master's, and/or doctoral degree education.
Entry-level professional practitioners, usually prepared through
a baccalaureate degree program, function as generalists. They
should provide direct health care and focus on ensuring coordinated
and comprehensive care. They should work collaboratively with
other health care providers to manage the needs of individuals
and groups. A master's-degree education prepares nurses for
advanced practice roles, including health promotion, the management
and delivery of primary health care, case management for the
chronically and acutely ill, community health, and administration.
Doctoral education should prepare nurses to expand the knowledge
base of nursing through research, advanced practice and/or
teaching.
The following specific guidelines are
relevant to the educational preparation of nurses for future
health care delivery.
- Faculty practice should be used as
a strategy for fostering links between schools of nursing
and their communities, and for promoting competence and
relevance in teaching and research.
- Changing modes of health care delivery
and emphasis on health promotion require that nursing education
increasingly emphasize settings such as homes, schools and
workplaces.
- Professional nursing education should
recognize and address the ways in which professional nursing
practice interfaces with and manages technical nursing practice.
- Baccalaureate-level education should
remain broad and provide a base for generalist nursing practice.
- Given the explosion of health care
knowledge, educators should give future consideration to
education beyond the baccalaureate degree as the basis for
entry into professional practice.
- The educational preparation of clinical
specialists, nurse practitioners, case managers, nurse midwives,
etc., should undergo examination with the goal of ensuring
a common educational core (and considering an appropriate
title) for all nurses prepared for advanced practice.
(See AACN publication, "The
Essentials of Master's Education for Advanced Practice Nursing.")
- Doctoral education in nursing should
ensure that those who are prepared to expand the knowledge
base of nursing also have a solid foundation in nursing
as a practice discipline.
- Schools of nursing should explore
various models of doctoral education. Consideration of models
for the preparation of nurses who expand nursing knowledge
through a primary emphasis in practice, teaching, and/or
research is warranted. Doctoral education in nursing has
developed to the point that programs should identify and
develop their unique and distinctive foci.
Program Evaluation and Outcomes
To meet the challenges of Nursing's
Agenda for Health Care Reform, the objectives of Healthy
People 2000 and Healthy People 2010, and evolutions
in health care delivery, nursing curricula and clinical practice
models should respond to major trends in health care.
- Program development, evaluation and
outcome measurements should be based upon anticipating and
responding to these trends. Existing regional and national
accreditation criteria and professional standards set by
nursing practice, nursing education and consumers of nursing
care should serve as guidelines. (American Association of
Colleges of Nursing, 1999, 1998, 1996; Commission on Collegiate
Nursing Education, 1998; National League for Nursing, 1991;
American Nurses Association, 1991)
- Nurse educators should measure the
compatibility of their programs with professional nursing
standards and health care trends.
- The educational program should receive
adequate resources and should include clinical practice
sites for interdisciplinary collaboration, case management,
primary health care, and health promotion and maintenance
opportunities in acute and long-term care.
- Evaluation plans should measure outcomes
that demonstrate students' critical thinking skills, interpersonal
skills, leadership, case management skills, and performance
of therapeutic nursing interventions (National League for
Nursing, 1991).
- Outcome criteria should include graduation
rates, placement of graduates in underserved areas, patterns
of employment, student and graduate satisfaction, professional
and personal development, and attainment of credentials,
scholarship, and service (National League for Nursing, 1991).
- Outcome evaluation tools should measure:
- the effectiveness of nursing programs
toward meeting the health objectives of the nation.
- consumer satisfaction with the
educational program and the nursing care provided by
faculty, students and graduates.
- health care system changes that
result from nursing action.
Nursing Research
Research in nursing and nursing education
has evolved in the last decade from a peripheral position
in the profession to one of the leading indicators of nursing's
participation in the scientific community. Nursing research
is essential to reduce the incidence of and sequelae from
disease and trauma, improve the quality of nursing care to
both individuals and communities, and assist in designing
strategies for delivery of nursing services to a diverse,
multi-cultural population. The establishment of the National
Center for Nursing Research (now the National Institute of
Nursing Research) at the National Institutes of Health in
the mid 1980s, and the establishment of doctoral programs
in nursing, which now total more than 70 nationwide, have
spurred the growth of nursing research.
This position statement's guidelines
for research are based upon the following assumptions:
- Nursing research focuses on improving
nursing practice with the goal of healthier outcomes for
all patients and clients.
- Nursing research studies human responses
to illness and treatment, health promotion and disease prevention,
delivery of nursing services, and nursing education.
- Integrated programs of nursing research
are necessary to maximize knowledge development, to incorporate
research into educational programs, and to translate research
into practice.
To adequately address today's health
problems, the integration of researchers and research programs
into nursing schools, and assimilation of nurse researchers
into the mainstream scientific community must occur. In order
to accomplish this, the following are recommended:
- Both private and public sources should
provide support for research training at both the pre- and
post-doctoral levels.
- Nurse researchers should be prepared
at the doctoral level in nursing programs and/or related
fields applicable to nursing practice.
- Institutional support for research
development of faculty should continue.
- Support for nursing research activities
should address the clinical problems relevant to the goals
of Healthy People 2000 and Healthy People 2010.
- Nursing research should emphasize
the integration of biological and psychological variables
in providing care to individuals, families, groups, and
communities. In addition, nursing research should emphasize
the creation of functional cost-effective systems. In particular,
research by nurses should focus on intervention and ultimately
target healthcare outcomes.
- Nursing research includes both quantitative
and qualitative methods and should focus on the following:
- Health promotion, health protection,
and preventive services.
- Underserved and under-researched
populations (e.g., women, culturally diverse, homeless).
- Under-researched issues (e.g.,
breast and testicular cancer) and issues that have multiple
consequences for society (e.g., substance abuse).
- Studies that contribute information
for health policy decision-making, and assist in the
design and evaluation of systems for delivery of nursing
services.
- Studies that evaluate the effectiveness
of innovative programs for delivering nursing education.
- Schools of nursing should support
faculty and students in disseminating and applying research
findings.
- Schools of nursing should foster participation
by faculty and students in interdisciplinary research.
The nursing profession must continue
to work with other disciplines, organizations, private and
public agencies, and legislative bodies to increase awareness
of the importance of the contribution of nursing research
to the nation's health. The profession must actively promote
the integration of nursing science into the mainstream scientific
community.
(Approved by AACN Membership: March 22,
1993)
(Revised: October 1999)
References
American Association of Colleges of
Nursing. (1999). Essential
Clinical Resources for Nursing's Academic Mission.
Washington, DC: Author.
American Association of Colleges of Nursing.
(1998). The Essentials
of Baccalaureate Education for Professional Nursing Practice.
Washington, DC: Author.
American Association of Colleges of Nursing.
(1996). The Essentials
of Master's Education for Advanced Practice Nursing.
Washington, DC: Author.
American Association of Colleges of Nursing
data. (1998).
American Association of Colleges of Nursing.
(January 1992). From hospitals into the community: The
push to primary care. (AACN Issue Bulletin). Washington,
DC: Author.
American Association of Colleges of Nursing.
(March 1999). Defining Scholarship
for the Discipline of Nursing (position statement).
Washington, DC: Author.
American Nurses Association. (1991).
Nursing's Agenda for Health Care Reform. Washington,
DC: Author.
Commission on Collegiate Nursing Education.
(August 1998). Standards
for Accreditation of Baccalaureate and Graduate Nursing Education
Programs. Washington, DC: Author.
Fagin, C. (1987). Faculty practice in
clinical specialties. Nursing Outlook, 35, 167-169.
Free, T., & Mills, B. (1985). Faculty
practice in primary care. Nursing Outlook, 33, 192-194.
Hegyvary, S. (1992). Educating nurses
for new practice environments. In C. Everts, P.P. Bottomworth
& M. Osterweis (Eds.), Human Resources for Health: Defining
the Future (pp. 133-140). Washington, D.C.: Academic Health
Centers.
Hegyvary, S.T. (1992). Nursing education
for health care reform. Journal of Professional Nursing,
1(8), 3.
Joel, L. (1985). The Rutgers experience:
One perspective on service education collaboration. Nursing
Outlook, 33, 221-224.
Langford, T. (1987). The politics of
faculty practice: The Dean's Role. Nursing Outlook,
35, 178-181.
McClure, M. (1987). Faculty practice:
New definitions, new opportunities. Nursing Outlook,
35, 162-166.
National Advisory Council on Nurse Education
and Practice. (1996). Report to the Secretary of the Department
of Health and Human Services on the Basic Registered Nurse
Workforce. Washington, DC: U.S. Department of Health and
Human Services, Division of Nursing.
National Center for Health Statistics.
(1999). Health, United States: 1999. Hyattsville, MD:
Author.
National Center for Health Statistics.
(1995). Vital and Health Statistics. Series 10, No.
199. Hyattsville, MD: Author.
National Center for Health Statistics.
(1999). Health, United States: 1998. Hyatttsville,
MD: Author.
National League for Nursing. (1991).
Criteria and Guidelines for the Evaluation of Baccalaureate
and Higher-Degree Programs in Nursing. New York: Author.
Shugars, D.A., O'Neil, E.H., & Bader,
J.D. (Eds.). (1991). Healthy America: Practitioners for
2005: an agenda for action for U.S. health professional schools:
a report of the PEW Health Professions Commission. Durham,
N.C.: PEW Health Professions Commission, Duke University Medical
Center.
Rodgers, M.W. (1986). Implementing faculty
practice: A question of human and financial resources. Journal
of Advanced Nursing, 11, 687-696.
U.S. Department of Health and Human Services.
(1991). Healthy People 2000. Washington, DC: Author.
U.S. Department of Health and Human Services.
(2000). Healthy People 2010. Washington, DC: Author.
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