Executive Summary
With constant changes predicted
in health care for the foreseeable future, it is imperative
that nursing education programs themselves act as agents of
change. It is the responsibility of nursing education, in
collaboration with practice settings, to shape practice, not
merely respond to changes in the practice environment. Ultimately,
nursing care will only be as good as the quality of the partnership
between nursing education and nursing practice.
Any vision for the future of nursing education
must emanate from nursing's core values. In particular, a
hallmark of nursing is the profession's emphasis on the whole
person. Although nursing involves assessment, diagnosis, and
technological skill, it also attends to human vulnerability
and helps people cope by providing comfort and counseling,
patient education, and health promotion to foster healthy
lifestyles, knowledge of one's illnesses, awareness of risk
factors, and self-care.
Moreover, nurses not only care for people,
but also tend the environments in which care happens. While
nursing education must prepare expert practitioners, schools
also have the responsibility to produce nursing professionals
who can participate as full partners in health care delivery
and in shaping health policy. As such, it is crucial that
nurses be prepared with the skills to negotiate the political
system and to remove artificial barriers that limit the profession's
ability to practice in the best interest of consumers. Nurses'
responsibilities increasingly will include educating the public
and policymakers of nursing's role within the overall scheme
of health care, of the range of nursing's skills and scopes
of practice, and of the relationships between nursing care
and positive outcomes for patients.
As members of interdisciplinary health care
teams and in other roles, nurses will be called upon to demonstrate
flexibility, accountability, and leadership. For example,
nursing must develop a balance between preparation for specialty
care and for primary health care, and must continue to differentiate
among levels of practice within the profession and in utilizing
assistive personnel.
Within the next decade, nursing higher education must be poised
to address the following priorities:
All Programs
- The development of skills in critical thinking
and clinical judgment should be the top curricular priority
in baccalaureate and graduate nursing programs.
- Nurses should be prepared to practice across
multiple settings, several of which will be nontraditional.
- Nursing curricula should increasingly emphasize
primary health care, patient education, health promotion,
rehabilitation, self-care, and alternative methods of healing.
More concentration in these areas, however, should not minimize
the focus on domains such as acute and tertiary care.
- Programs must strive for ethnic and racial
diversity among students and faculty which more closely
mirrors society. This will require more aggressive and creative
recruitment and retention programs.
- All curricula should focus, at appropriate
levels, on case management, health care policy and economics,
research methods, quality indicators, outcome measures,
financial management, legislative advocacy, trends toward
privatization, and management of data and technology.
Baccalaureate Programs
- Preparation of nurses at the baccalaureate-degree
level is the minimum qualification to function in professional
practice roles.
- Baccalaureate students should be skilled
in delegation as well as in case and system management,
should be provided with learning and practice experiences
in diverse settings, and should acquire skills in planning
and integrating care for people as they, too, move across
settings.
- While options for educational mobility should
be available, reliance on articulation agreements should
not decrease the profession's efforts to encourage direct
entry into baccalaureate and higher-degree programs.
Master's Programs
- With roles for advanced practice nurses
expanding rapidly and demand for care increasing across
age groups and settings, the chief priority for master's
curricula should be the preparation of advanced practice
nurses. However, schools should continue to offer specialization
for students who choose to pursue indirect care roles --
such as management, administration, and informatics -- to
prepare leaders in systems of care.
Doctoral Programs
- The majority of doctoral programs in nursing
should continue to emphasize clinically relevant research
that builds the science for nursing practice.
- Doctoral programs also have the responsibility
to prepare future faculty by providing frameworks and tools
for moving to new methods and models of education.
Responsibilities of Faculty
- Nursing faculty at all levels must be current,
clinically competent, and sound in the art and science of
teaching.
- Doctorally prepared faculty will be called
upon increasingly to base their teaching in the reality
of active clinical practice, a development that likely will
see practice become as integral to the faculty role as teaching,
research, and service. Such faculty should be afforded schedules
that facilitate practice time.
Moreover, in this period of dynamic change, some freedom from
the focus on regulation is needed to allow for a climate of
innovation. Nursing must encourage creativity and risk-taking
in order to develop the most cost-effective models for the
future.
A Vision of Baccalaureate
and Graduate Nursing Education: The Next Decade
Nursing Schools as Agents
of Change, Keepers of Core Values
With constant change predicted for health care delivery
for the foreseeable future, it is imperative that nursing
education programs themselves act as agents of change. It
is the responsibility of nursing education, in collaboration
with practice settings, to shape practice, not merely
respond to changes in the practice environment. Ultimately,
nursing care will only be as good as the quality of the
partnership between nursing education and nursing practice.
Any vision for the future of nursing education
must emanate from nursing's core values. These values have
been well-articulated in two AACN documents, Essentials
of College and University Education for Professional Nursing
and The Essentials of Master's Education for
Advanced Practice Nursing.1-2 In particular,
a hallmark of nursing is the profession's emphasis on the
whole person. Nursing's focus on promoting optimal health
is broadly defined, encompassing not only every stage of development,
but also the continuum of health and illness as well as physical,
emotional, mental, social, and spiritual dimensions. Although
nursing involves assessment, diagnosis, and technological
skill, it also attends to human vulnerability and helps people
cope by providing comfort and counseling, patient education,
and health promotion to foster healthy lifestyles, knowledge
of one's illnesses, awareness of risk factors, and self-care.
At its core, nursing recognizes that clinical
judgments have as much to do with values and ethics as they
do with knowledge and technology. To nurse is to know oneself
as fully as possible and to use one's personal presence in
the context of privileged intimacy to come to know others
who are in need of care.
In a nursing context, the distinction between
disease and the illness experience lends understanding to
the meaning of illness in a person's life. By itself, such
meaning is a vital form of healing that can overcome the sense
of alienation, loss of self, and loss of social integration
that frequently accompany illness. This distinction is fundamental
and unique to nursing and must remain central to baccalaureate
and graduate nursing education programs of the future.
Finally, nurses not only care for people,
but also tend the environments in which care happens. While
it is the responsibility of nursing education to prepare expert
practitioners, schools must also produce nursing professionals
who can participate as full partners in health care delivery
and in shaping health policy. As such, it is crucial that
nurses be prepared with the skills to remove artificial barriers
that limit the profession's ability to practice in the best
interest of consumers.
Underlying Assumptions
A range of external and internal forces will continue
to drive health care delivery and nursing education for the
near future. These include:
Economic: As downsizing moves
throughout major industries, it has taken hold in other areas
of the economy, including reduced federal financial support
for initiatives in education and health care. These changes
not only have boosted competition for scarce resources --
such as the need among public and private higher education
institutions to compete for the same revenue streams -- but
also have given rise to a heightened consumerism. As a result,
increasing demands for quality, accountability, and cost-effectiveness
are shifting the focus of evaluation from process to outcome
measures, and include the emergence of patient satisfaction
and functional status as important indicators of quality health
care.
Demographic: America is confronted
with growth at both ends of the age continuum -- not only
increasing numbers of elderly and retirees, but also increases
in the youth population (age 0-17) through the first years
of the 21st century before declining after 2010. Moreover,
by 2020, a slim majority of U.S. children will be non-white.
3
Workforce: Although, generally,
the population is more racially diverse and mobile than ten
years ago, the current RN pool does not sufficiently mirror
the ethnic diversity of clients who receive care. While representing
nearly 25 percent of the population, racial and ethnic minorities
comprise only about 10 percent of the nation's 2.5 million
registered nurses. 4 At 12 percent, the ranks of
racial and ethnic minorities enrolled in master's-degree programs
that prepare nurses for advanced practice remains a continuing
challenge.5
The demographics of health care project that
by the year 2000, there will be surpluses of nurses, physicians,
and pharmacists as health professionals realign to provide
care that involves fewer specialists and is more community-based.
However, projected surpluses of RNs are more accurately a
matter of maldistribution of the current supply, which is
marked by a continued overabundance of associate-degree nurses,
projected shortages of baccalaureate-prepared RNs, and a predicted
undersupply of master's and doctorally prepared nurses for
advanced practice, teaching, and research. 6 At
42, the average age of RNs currently in the workforce will
likely produce shortages as retirements of large cohorts occur.7
Indeed, the federal Division of Nursing has recommended that
at least two-thirds of the basic nurse workforce have at least
baccalaureate or higher degrees in nursing by the year 2010.8
Technological: Technology
has dramatically altered practice, teaching, and learning
environments in nursing, as well as the way in which nurses,
educators, and students communicate. While easier to access,
information is often harder to control because of the speed
at which it is generated and communicated. Indeed, access
to comprehensive and up-to-date databases has increased both
the speed of clinical decision-making and the responsibility
of providers to ensure that such quick decisions are equally
sound. Moreover, advances in technology not only have resulted
in shortened hospital stays as less-invasive techniques are
developed, but the portability of high technology also has
helped to shift the focus of complex care for the acutely
ill to sub-acute care centers, skilled nursing facilities,
homes, and rehabilitation centers outside the hospital.
Higher Education: The
best colleges and universities are redistributing resources
to maximize excellence in teaching and scholarship. At the
same time, consumer scrutiny so prevalent in the general economy
has moved into higher education -- itself experiencing escalating
tuition and accumulated debt -- leading consumers to call
for value and social relevance in education. As a result,
consumers and educators are placing new emphasis on evaluating
the outcomes of education, not merely the process.
In addition, though universities have focused on specialized
knowledge, there is a growing emphasis on building interdisciplinary
knowledge, a development related in part to globalization
and to the need to make broader use of resources. The need
for partnerships among academic institutions is receiving
increased attention, as well, as pressure grows for more cost-effective
use of resources and easier mobility across academic programs.
In nursing, as in higher education, cuts in
federal and state funding have stimulated entrepreneurial
efforts and joint ventures with industry to supplement the
traditional funding sources of tuition, general revenues,
endowments, scholarships, and grants. Such partnerships are
expanding as a variety of pressures threaten to drain resources.
Among these are aging campus infrastructures and projected
increases in the numbers of college undergraduates by the
year 2005. 9
Health Care Delivery:
Treatment continues to shift from hospital-based, fee-for-service
care to care that is pre-paid and community based with an
emphasis on primary care and prevention. Indeed, it is estimated
that one-half of the nation's hospitals will close and 60
percent of hospital beds will be eliminated by the year 2000.10
As do other industries, health care faces pressing demands
for consolidation and efficiency. The increasing pace of hospital
downsizing, continued reports of substitution of unlicensed
personnel for registered nurses, growing competition for health
care markets, and the creation of large health care networks
through mergers and buyouts of hospitals have generated enormous
tension between the drive to privatize on the one hand and
calls for increased regulation on the other.
Within nursing, the mounting complexities
of patient care and of the health system itself have accelerated
the move to differentiated levels of practice, advanced education
and certification, and interdisciplinary training. In addition,
lack of access to health services among the underserved and
disenfranchised have made nursing's advocacy and programs
on their behalf ever more important.
In particular, the push toward primary care
has increased demand for nurse practitioners and other advanced
practice nurses (APNs), and boosted the need for doctorally-prepared
nursing faculty who are certified practitioners and clinical
specialists. Increased demand, however, also has brought increased
scrutiny and further attempts to restrict the scope of practice
for APNs as competition among health professions intensifies.
Needed Roles for Professional Nurses in
the Emerging Health Care System
In the future, nurses' roles will be less clearly
defined than in the past. Traditional boundaries across health
professions will blur and overlap. In the effort to optimize
complementary talents, nursing's specific contribution to
a multidisciplinary team will depend in part on the nurse's
educational background and expertise and on the preparation
and expertise of other team members. As a result, nurses'
roles in the emerging health system not only will share common
elements with all team members, but also will have features
unique to nursing.
Across the health professions, demand has accelerated
for creative thinking, pattern recognition, and problem resolution.
At the same time, burgeoning technological advances and increased
access to information require health professionals who are
"knowledge workers" -- able to manage information
and high technology on the one hand and complicated clinical
judgments on the other.
In addition, health delivery will continue
to emphasize primary and preventive care, cost-effective services
across a variety of settings, and care delivery in more non-traditional
sites such as neighborhood clinics, schools, churches, and
the workplace where supervision and consultation often are
less available. In particular, the focus of the health system
on the care of entire populations will require effective programs
of health promotion, disease prevention, and early detection
of illnesses and risk factors.
Increasingly, the health care system will require
decision making and services that respond to complex, unpredictable
situations involving social, physical, economic, technological,
and political factors. The knowledge and skills needed to
practice in this environment must be grounded in the sciences
and humanities, in nursing and other health care research,
and in leadership principles that are applicable both to acute
care and community-based care settings. As such, preparation
of nurses at the baccalaureate-degree level is the minimum
qualification to function in this professional role.
Moreover, all members of the health care team
will be required to monitor and control costs and to evaluate
quality and outcomes of the services they deliver. As a result,
providers not only will need to understand the roles and contributions
of other team members, but must articulate and demonstrate
their own roles effectively.
For nurses, such cross-discipline involvement
will call for roles that emphasize flexibility, accountability,
and leadership. For example, nursing must develop a balance
between preparation for specialty care and for primary health
care; however, even in acute-care roles, professional nurses
will be expected to provide preventive interventions as appropriate.
Nurses also will be required not only to manage data, but
to have the ability to retrieve and interpret data to evaluate
nursing activities and interventions.
The Need to Recognize Differentiated
Practice and International Innovations
Additionally, both in providing and overseeing
care, nurses must continue to differentiate among levels of
practice within the profession and in utilizing assistive
personnel, and must be able to work with multiple skill levels
in these practice models.
In a world economy, nurses must be ready to
respond to health care knowledge and innovations gained from
the international community. While the demand for culturally
competent care applies to all health care disciplines, in
the context of nursing it must include cultural knowledge
relevant both to patient education and self-care, as well
as to more routine physical assessment and management of symptoms.
As nurses advocate for maintaining health
in individuals, families, and communities, they will practice
amid rapid change as systems interact and reconfigure in an
effort to deliver high-quality services at a reasonable cost.
Specifically, nursing will play a major role in developing
and implementing changes to improve the functioning of the
health system. In doing so, nurses must possess analytical
ability, as well as skills in communication, in working with
groups, and in negotiating the political system. In particular,
nurses' responsibilities increasingly will include educating
the public and policymakers of nursing's role within the overall
scheme of health care, of the range of nurses' skills and
scopes of practice, and of the relationships between nursing
care and positive outcomes for patients.
Needed Changes in Baccalaureate and
Graduate Nursing Programs
Nursing curricula must be geared toward the
changing demographics of the population, new and expanded
roles for nurses, and the escalating need for interdisciplinary
practice, among other critical forces. Within the next decade,
nursing higher education must be poised to address the following
priorities:
All Programs: Evolving roles
for nurses will affect the knowledge and competencies needed
at all levels of practice. Students in baccalaureate and graduate
curricula should be prepared in programs that are based on
core nursing values, are flexible and innovative, foster interdisciplinary
collaboration, encourage an attitude of lifelong learning,
and are at the leading edge of health care knowledge and delivery.
The development of critical thinking and clinical judgment
skills should be the top curricular priority.
Programs must strive for ethnic and racial
diversity among students and faculty which more closely mirrors
society. This will require more aggressive and creative recruitment
and retention programs. Such activities include financial
assistance, mentoring and role model programs starting with
junior- and high- school students, advanced placement for
high-school students into nursing baccalaureate programs,
recruitment and support for graduate students, and support
for entry and progression in faculty roles. Equally important,
nursing curricula must be made more culturally relevant for
ethnic and racial minority populations who, by the year 2050,
are projected to comprise nearly half of all Americans. 11
Other types of diversity also need attention; for example,
the entry of males into nursing is gradually increasing and
should continue to be encouraged.
Schools must produce nurses capable of providing
care that is not only high-quality, cost-effective, and accessible,
but also accountable, individual- as well as population-based,
culturally relevant, and focused on the whole person across
the lifespan. Nurses' knowledge should be globalized with
an awareness of the scope of services of other health professions
and of health care advances in other nations. In addition,
nurses should be prepared to practice across multiple settings,
several of which will be nontraditional.
Nursing curricula should increasingly emphasize
primary health care, patient education, health promotion,
rehabilitation, self-care, and alternative methods of healing.
More concentration in these areas, however, should not minimize
the focus on other domains such as acute and tertiary care.
Moreover, attention to primary care should include opportunities
to retrain staff nurses who are displaced by hospital restructuring
or who otherwise seek to practice in primary care and community-based
roles.
In addition, all curricula should focus, at
appropriate levels, on case management, health care policy
and economics, research methods, quality indicators, outcome
measures, financial management, legislative advocacy, trends
toward privatization, and management of data and technology.
Finally, both theory and clinical components of community
health should be an important focus at all levels of baccalaureate
and graduate nursing education.
Different Education, Different
Roles
Baccalaureate Programs:
Baccalaureate-prepared nurses will assume more responsibilities
for managing health care delivery involving a variety of providers.
As a result, graduates must be skilled in delegation, as well
as in case and system management. Baccalaureate students should
be provided with learning and practice experiences in diverse
settings, and should acquire skills in planning and integrating
care for people as they, too, move across settings.
Because the majority of RNs do not have baccalaureate
or higher degrees, it is important that options for educational
mobility be available. However, while articulation agreements
have provided opportunities for upward mobility in nursing,
reliance on them should not decrease the profession's efforts
to encourage direct entry into baccalaureate and higher-degree
programs.
Master's Programs: With
roles for advanced practice nurses expanding rapidly and demand
for health care increasing across age groups and settings,
the chief priority for master's curricula should be the preparation
of advanced practice nurses (APNs). However, schools should
continue to offer specialization for students who choose to
pursue indirect care roles -- such as management, administration,
and informatics -- to prepare leaders in systems of care.
Master's education will move toward a blending
of primary- and specialty-care content, such that APN graduates
can more flexibly serve populations across the care continuum.
As health care facilities realign into larger and larger networks,
master's graduates -- regardless of specialty -- should be
prepared to create and evaluate systems that integrate care
across settings.
Doctoral Programs: Doctoral
programs in nursing prepare graduates either for academic
roles including a combination of research, education, and
practice, or for careers as advanced clinicians, administrators,
researchers, and public policy. The majority of doctoral programs,
however, focus on research and must emphasize clinically relevant
research that builds the science for nursing practice.
At this time, research is needed that focuses
on the relationships between nursing care and patient outcomes,
on the effectiveness of differentiated practice roles for
nurses, and on identifying the appropriate mix of nursing
and other health care providers that will be required to serve
health care needs adequately. Doctoral programs should strive
to promote synergy among teaching, research, and clinical
practice. Moreover, doctoral programs have the responsibility
to prepare the faculty of the future by providing frameworks
and tools for moving to new methods and models of education.
Responsibilities of Faculty:
Nursing faculty at all levels must be current, clinically
competent, and sound in the art and science of teaching. In
particular, doctorally prepared faculty will be called upon
increasingly to base their teaching in the reality of active
clinical practice, a development that likely will see practice
become as integral to the faculty role as teaching, research,
and service. Moreover, multidisciplinary perspectives and
interactions enhance nursing education; collaboration between
nursing and non-nursing faculty is encouraged.
Advanced technology should be used to improve
teaching methods at all program levels. In addition, creative
approaches to faculty development are essential if nursing
education is to meet the challenges of the future. Indeed,
as demand for advanced practice nurses has accelerated, the
need for doctorally prepared faculty who are certified practitioners
and clinical specialists has risen dramatically. Such faculty
should be afforded schedules that facilitate practice time.
Finally, it is important to acknowledge that
nursing has emerged from a period characterized by standard
setting and a focus on regulation. These efforts have produced
positive outcomes for care delivery and for the development
of the profession. In this period of dynamic change, some
freedom from the focus on regulation is needed to allow for
a climate of innovation. The profession must encourage creativity
and risk-taking in order to develop the most cost-effective
models for the future.
AACN Task Force on the Vision of
Baccalaureate and Graduate Nursing Education
Members
Jane S. Norbeck, DNSc, Dean (Task Force
Chair) School of Nursing
University of California - San Francisco
Sarah B. Keating, EdD, Dean
Samuel Merritt-Saint Mary's Intercollegiate Nursing Program
Oakland, CA
Judith B. Krauss, MSN, Dean
School of Nursing
Yale University
New Haven, CT
Rona F. Levin, PhD, Director
Division of Health Sciences
Felician College
Lodi, NJ
E. Jane Martin, PhD, Dean
School of Nursing
West Virginia University
Morgantown, WV
Barbara Hazard Munro, PhD, Dean
School of Nursing
Boston College
Chestnut Hill, MA
Doris Starks, PhD, Dean
Helene Fuld School of Nursing
Coppin State College
Baltimore, MD
AACN Staff
Joan Stanley, PhD
Director, Education Policy
References
1. American Association of Colleges of Nursing.
(1986). Essentials of College and University Education
for Professional Nursing, Washington, DC: Author. [This
publication is currently undergoing a major revision, which
is slated for completion in 1998.]
2. American Association of Colleges of Nursing.
(1996). The Essentials of Master's Education for Advanced
Practice Nursing. Washington, DC: Author.
3. Hodgkinson, Harold L. (1995). "A Demographic
Look at Tomorrow," citing National Center for Education
Statistics, Youth Indicators, 1991, in Proceedings of the
Third Annual Congress of Health Professions Educators, pp.
4, 14. Washington, DC: Association of Academic Health Centers.
4. Bureau of the Census. Washington, DC: U.S.
Department of Commerce; and Division of Nursing. (March 1996).
Advance Notes from the National Sample Survey of Registered
Nurses, Washington, DC: U.S. Department of Health and
Human Services.
5. American Association of Colleges of Nursing.
(1996). 1995-1996 Enrollment and Graduations in Baccalaureate
and Graduate Programs in Nursing, p. 13. Washington, DC:
Author.
6. Health Resources and Services Administration.
(March 1990). Seventh Report to the President and Congress
on the Status of Health Personnel in the United States,
p. VIII-39. Washington, DC: U.S. Department of Health and
Human Services.
7. Division of Nursing, U.S. Department of
Health and Human Services, see note 4.
8. National Advisory Council on Nurse Education
and Practice. (October 1996). Report to the Secretary of
the Department of Health and Human Services on the Basic Registered
Nurse Workforce, p. 9. Washington, DC: Division of Nursing,
Health Resources and Services Administration.
9. National Center for Education Statistics.
(February 1995). Pocket Projections: Projections of Education
Statistics to 2005, p. 4. Washington, DC: U.S. Department
of Education.
10. Pew Health Professions Commission. (November
1995). Critical Challenges: Revitalizing the Health Professions
for the Twenty-First Century, p. 10. San Francisco: University
of California, Center for the Health Professions.
11. Bureau of the Census. Population Projections
of the United States by Age, Sex, Race, and Hispanic Origin:
1992-2050, publication #P25-1092. Washington, DC: U.S. Department
of Commerce.
Approved by AACN Membership -- October 27,
1997
|
