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June 7, 2015


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Nursing is in the midst of revolutionary changes. How are these
changes affecting the profession todayand how are they likely to affect it in
the future? As we move forward, nursing will continue to evolve. But some of
the basics wont changebasics such as advocating for patients, seeing how
all the pieces fit together for the patient and, most importantly, caring for
the patient as a human being.
I. Portability and mobility
According to Tim Porter-OGrady, RN, EdD, Portability and mobility are
the cornerstones of technotherapeutic interventions, The growth in
freestanding clinics, ambulatory care centers, and other nonhospital settings
supports his view. Technology will extend patients lives. Many Americans are
aging in place, with communities finding ways to support older people in
their homes. Futurist Andy Hines, MS, says, Baby boomers are going to want
to avoid institutions for themselves and their parents.
These forces mean that much of the patients healing takes place
where nurses dont typically deliver round-the-clock carethe home.
Unfortunately, most nurses have been educated in a hospital-based model,
which doesnt mesh with todays trends. Porter-OGrady urges us to
remember that patients dont necessarily benefit from a hospital stay. There
is a direct line from length of stay to increased morbidity and mortality.
Hines remarks, Theres a shift away from institutional care toward
individual responsibility, and a move from hospitals and nursing homes to
retail, kiosks, and home. He adds that consumers want more personal
control over their healthcare, so we can expect more self-diagnostic tests
and innovative ways to deliver care. Hospital-based nurses also need to
focus on helping patients make the transition to where theyll be healingat
II. Evidence-based practice
EBP is one reason facilities designated as Magnet hospitals by the
Magnet Recognition Program have been so successful: Theyve set up
systems that foster evidence-based care, bringing improved patient care and
nurse satisfaction. EBP also serves as the foundation for the disease
management work done by nurse practitioners (NPs) and many other nurses.
III. Emphasis on safety and quality
Patient safety and quality of care are two trends that have benefited
nursing. Rebecca M. Patton, RN, CNOR, cites the National Quality Indicator
Database as an example of a program thats tracking nurses impact on
patient care outcomes. This database of nurse-sensitive indicators, with data
from almost 1,000 hospitals, is one of several that show nurses importance

in the delivery of safe, high-quality care in every setting. Because of the

quality push, healthcare workforce leaders may see more pay for
performancepayment by third-party or government payors based on the
quality of care delivered by the facility.
III. High times for high-tech
The explosion of medical technology has led to myriad lifesaving and
life-enhancing inventions, including spare body parts ranging from knees to
thumbs and dramatically improved sensors and diagnostics. Hines says
medical devices are getting more precise, user friendly, and cost effective.
Heres a rundown of a few areas where technology is making a big impact.
Genes and stem cells. Researchers are linking more and more diseases to
genes, with tremendous implications for educating patients about their
conditionsand tremendous potential for ethical dilemmas regarding genetic
Robots in the OR. Computer-assisted surgery has moved to the next level.
Robots have elbowed their way onto the operating-room bed and into the
perioperative team. Although too expensive to use for every surgery, robots
have proven their mettle in complex procedures and those that require
manipulation in a tight area. Of course, robots wont replace surgeons or
nurses, but they can enhance their abilities. Robots also can free up nurses
to spend more time with patients. And, given our aging population and the
extension of lives through medicine and technology, nurses will need every
means of support possible.
IV. Nursing workforce
As recently as 2004, a national survey found that 82% of nurses
thought there was still a nursing shortage. Thats consistent with others
perceptions: Earlier that same year, 81% of physicians perceived a nursing
shortage where they admitted patients. In 2005, 74% of hospital chief
nursing officers and 68% of chief executive officers also perceived a
shortage. According to Peter Buerhaus, RN, PhD. Clearly the nursing
shortage isnt as intense as in 2001 and 2002, but it has by no means gone
away. But Buerhaus thinks were experiencing the calm before the storm. In
April 2006, the American Hospital Association reported a vacancy rate of
8.5% in nursing job openings. In his experience, vacancy rates of 9% usually
indicate a shortage. He points out that the demand for nurses is rising, with
only slow increases in supply, and that nurses earnings flattened in 2004
and 2005.
A. Greying nurses
Whether or not theyre satisfied with their jobs, nurses will continue to
spot grey hairs in the mirror as they age. The physical workplace
environment will need to be adapted to keep older nurses in the workforce.
We need their experience, says Burnes Bolton, but we need to take the
burden out of care. Technology can help accomplish this. As the core of the
nursing workforce nears retirement, younger nurses are entering the
profession, creating intergenerational teams. Nurses of different age-groups
need to understand and accept each others perspective and appreciate
what everyone brings to the team.
B. Other factors affecting the nursing workforce
Physician shortages. A shortage of physicians will increase the demand for
NPs. The sense is that the physician shortages are severe, says Buerhaus,

and these shortages arent likely to end any time soon. As the demand for
healthcare keeps growing, were going to need NPs in huge numbers, and
they could take over much of what medicine does today in our lifetime.
Foreign nurses. Buerhaus foresees more foreign nurses working in the
double or triple todays number. He speculates that by 2020, as much as
25% of our nursing workforce may have received their nursing education
outside the United States. Hines agrees that foreign nurses are here to stay.
Common standards are needed for the emerging global workforce. At the
same time, Patton cautions that using foreign-educated RNs must not detract
from the need to offer all nurses a better work environment.
Staffing ratios. Will legislated ratios play a role in the upcoming demand
for nurses? Aiken and Buerhaus say no. Aiken believes legislated ratios will
never dominate because most of the institutions in this country are in the
private sector; few are government owned. However, she does think
legislation on public reporting will become more commonand these reports
may include ratios. She predicts hospitals will increasingly move to better
staffing as a result of the evidence. Buerhaus warns, If ratios catch on and
become federally mandated, it would lead to the demise of the nursing
profession. The public would lose trust because they wont really see better
outcomes; the science isnt there to show it.
Healing spaces, empowered nurses. Although nurses work
environments are improving, more needs to be done. Hospitals already are
working on reconfiguring rooms so nurses dont have to walk so far and
supplies are easily accessible. Some have gone a step further, creating
healing spacesquiet areas with calm colors, meditation rooms, and
gardens. Some hospitals are working to make the environment more
personally satisfying by offering mindfulness retreats and posting affirmation
messages that nurses can read while on duty. Still others have adopted
caring models that refocus nursing delivery on caring.
Seeking a balance. Hines predicts the power will shift from the healthcare
institution to the individual nurse as nurses seek to balance work and
personal life work. The schedule and quality of life for many nurses is
dreadful, he says. You have these long, tiring shifts of 12 hours on your
feet, and lots of on-call and overtime. This runs counter to the social trend
toward a greater work-life balance. Right now, the institutions have power
over the nurses, but that could shift as nurses realize the opportunities
outside the institutional setting.
V. Can technology help get nurses back to the bedside?
Nurses spend less than 40% of their time on direct patient care, says
Burnes Bolton.
Technology can help turn that around. Burnes Bolton points out that some
devices already in use are aimed at reducing the time nurses spend hunting
and gathering and communicating multiple times in getting or giving
information to team members. These products include tools nurses wear to
improve communication and monitor patients remotely, and tools that help
nurses and other team members get the information they need to make
decisions. Many of these devices have forcing functions, such as built-in
safety checks used on smart infusion pumps.
Smart technology is used in many other ways as well. Some beds
detect blood flow in the patients legs and alert the nurse to possible deep
vein thrombosis. Special patient vests collect physiologic data and transmit it

to a healthcare workers personal digital assistant. Smart technology also

is being used to promote medication safety.
These communicating and data-gathering devices allow nurses to
interpret information and spend more time with patients. But all of this
technology has a downside: Many of these products dont talk to each
VI. Facing the faculty shortage
Lancaster believes that in the next 5 to 10 years, nursing schools will
face a worsening crisis, with enrollment increasing as more faculty members
retire. Faced with this situation, schools are looking for options. More and
more advanced practice nurses in hospitals are participating in the education
of students, says. This partnership benefits both the students and the
clinicians, who believe it keeps them on top of their game. Some schools are
developing certificate programs to help nurses prepare to be faculty
members. These nurses have a shared teaching/clinical position or alternate
periods between practitioner and teacher. Schools will continue to rely on
practice partners for help in educating students, Lancaster says.

VII. Globalization and the Internationalization of Education

Evolving technologies are transforming both the formal and informal
acquisition of knowledge. Information is accessible electronically; and people
with common interests, e.g., students, researchers, and innovators,
exchange knowledge freely via the Internet. The development of a
knowledge economy has made intellectual capital a valuable possession.
Consequently, knowledge production through education has become an
increasingly competitive industry (World Bank, 2002, 2008). Education has
become a business in the globalized world and is seen as both an investment
and an export commodity. Educational entrepreneurs invest in students as
they serve those seeking higher education credentials. When education is
marketized, the concepts of business become more pronounced, as noted
when learners are viewed as customers rather than participants.
VIII. Exporting of Education
A. Throughout Academia
There is a worldwide demand for higher education due to the
increasing labour market needs for highly skilled workers, such as nurses.
The United States (US), Britain, and Australia are the three leading exporters
of higher education, but other developed countries also play a part (Bollag,
2006, Shepherd, 2007). In the US, education and training rank among the
nations top service exports (Lenn, 2002; Lewin, 2008). Exported educational
services are delivered in various ways: (a) as students travel abroad to
receive their education; (b) as education is delivered to them through
distance learning; and (c) as educational institutions from one country
provide onsite classes in another country, often through establishing branch
campuses and/or franchises (King, 2006; Knight, 2006; Machado dos Santos,
2000). Colleges and universities in developed countries engage in various
partnerships. Some partnerships involve mutually beneficial exchanges of
faculty and students. In other arrangements, faculty members from one
university are contracted as instructors or consultants to establish new
departments in an overseas institution.
B. Exporting of Education in Nursing

Despite international differences in nursing education and practice, a

number of mechanisms allow nurses to migrate throughout the world. In
some source countries, there is a deliberate policy of educating nurses for
export. This investment in human resources can result in generous
remittances to the home country. A strategic method of profiting from
surplus human resources is to prepare migrants to find jobs abroad and
contribute to the economy of their home country through remittances to
family members. In developing countries, educated but underutilized workers
are among the first to migrate when opportunities become available to them
(Abella, 1997; Baumann, Blythe, Rheaume, & McKintosh, 2006; Blythe &
Baumann, 2008).
In the 1950s, the Philippines began to prepare nurses for export,
mainly to the US (Brush & Solchalski, 2007; Choy, 2004). Educated in English
with American-based curricula, Filipino nurses have migrated to the Middle
East and throughout the developed world. The Philippines Overseas
Employment Administration has reported that nearly 88,000 nurses left the
Philippines between 1992 and 2003, but this may be an underestimate
(Perrin, Hagopian, Sales, & Haung, 2007).
Following the example of the Philippines, the Indian government also
supports the export of nurses (Healey, 2006, Thomas, 2006). The importance
of this nurse export business is reflected in the rapid growth of nursing
schools in India (Thomas, 2006). Many groups profit from this nurse
migration. Khadria (2007, p. 1433) describes this process in India as
business process outsourcing. It includes a comprehensive training-cumrecruitment-cum placement for popular destinations like the United Kingdom
(UK) and the US through a proliferating agency system. China and Korea are
beginning to follow a similar path (Fang, 2007). The large population and
growing tertiary education markets will facilitate this production of nurses for
IX. Current Standards and Harmonization in Transnational Nursing
A critical issue in transnational nursing education is the absence of a
body that has international authority to monitor educational standards
worldwide, even though some attempts have been made to establish
international standards that reconcile standards with cultural diversity. There
is also a lack of internationally sanctioned mechanisms for making
comparisons among programs in different countries. The latter is particularly
important because educational institutions that wish to be major
international players need accreditation to attract students and to promote
quality education.
There is, however, a strong history of accreditation within countries.
Accreditations for professional programs are strong but are largely in
country. For example, the US and Canada have well established systems of
voluntary accreditation in higher education (Eaton, 2006). National
accrediting organizations assure common standards and expectations. These
organizations are often called upon by other countries to send teams to
adjudicate accreditation status for foreign programs. Examples of established
nursing accreditation programs are the National League for Nursing
Accrediting Commission (NLNAC) and the American Association of Colleges of
Nursing (AACN) in the US; and the Canadian Association of University
Schools of Nursing (CAUSN). The NLNAC accredits nursing programs of all
levels, while the AACN accredits baccalaureate programs for nurses who will
be entering nursing with a baccalaureate degree. It advocates the
baccalaureate as the minimum educational requirement for professional
nursing practice (AACN, 2000).

The European Union has paid considerable attention to addressing the

problem of reconciling cultural diversity with standards. In 2001, the Lisbon
Recognition Convention Committee adopted a Code of Good Practice in the
Provision of Transnational Education (Council of Europe, 2008). In a more
direct attempt to reconcile diversity and standards, a component of the
Bologna process, titled Tuning Educational Structures in Europe, has
examined structures such as curricula. This document is intended to promote
points of reference, convergence, and common understanding as the basis of
curricula that would lead to the development of common key competencies,
while protecting the rich diversity of European education (Marrow, 2006).
Additional attempts to establish standards for transnational education
include the Guidelines on Quality Provision in Cross-Border Education
prepared by the United Nations Educational, Scientific, and Cultural
Organisation (UNESCO) and the Organisation for Economic Co-operation and
Development (OECD) (Davies & Wong, 2006). However, students who require
acceptable credentials must themselves exercise great caution because
there is always the potential for fraud or exploitation. The Council of Europe
(2008) advises potential students to be extremely vigilant about spurious
claims of endorsement in stating, We wish to make it clear that the Council
of Europe does not recognize or in any other way bestow legitimacy on any
higher education institution, program or provision.
XI. Trends and Future Directions in Harmonizing Nursing Education
Nurses have existed in many cultures since ancient times (SapountziKrepia, 2004). From its foundation in 1899, the International Council of
Nurses (ICN) has envisioned an international federation of national nursing
organizations that would ensure high standards of nursing education and
practice globally. Its founders reasoned that principles governing nursing
education and practice should be the same in every country (ICN, n.d.).
Unfortunately in the early 20th century, as nursing established itself as a
profession, globalization waned. Two world wars and the Cold War meant that
the profession diversified. This resulted in a great deal of variation in the way
nurses were educated.
In addition to differences in education, the nursing profession varies by
country in how it is regulated. In a number of countries, to protect the public,
regulated professions have designated standards for their members and
reinforced these standards by withholding registration from individuals
lacking appropriate educational or other credentials (ICN/World Health
Organization [WHO], 2005). In other countries, regulation has taken a variety
of forms; and in some countries, nursing has not yet become an
autonomous, regulated profession. Differences in regulatory criteria are
barriers to internationalization. Where regulation occurs at the regional or
provincial level, mobility within a country is an issue (WHO/Sigma Theta Tau
Honor Society of Nursing [STTI], 2007). Yet data collected from the
Organization for Economic Cooperation and Developments (OECDs) 30
member countries shows that about 11% of nurses in these countries are
foreign educated (2007). This high proportion of foreign nurses indicates that
a measure of accommodation exists among the divergent systems of
education and regulation allowing nurses to practice outside their countries
of origin.
Although the ideal of worldwide standards for nurses promoted by the
ICN for over a century remains unrealized, the forces of globalization have
created an impetus for change. Education of health professionals, specifically
nurses, cannot be entirely homogenous given population health issues, such
as endemic diseases, along with social, cultural, and economic differences.

However, standards for nursing education need to be established throughout

the world to provide a guide for local services and to assure a minimum
standard for important issues such as essential qualifications for nurse
educators. There have been several initiatives to identify and address
barriers to achieving global standards.
Among the projects focusing on quality of nursing education is the
recently formed Joint Task Force on Creating a Global Nursing Education
Community. This initiative is designed to share information and promote
quality standards. A meeting led by WHO and STTI was held in Bangkok,
Thailand, in December 2006. The goal was to initiate the development of
global standards for basic nursing and midwifery education and to address
patient safety and quality of care issues that result from the large-scale
migration of healthcare providers. Major themes included the development of
global standards for program admission criteria, program development
requirements, program content components, faculty qualifications, and
program graduate characteristics (WHO/STTI, 2007).
Aspects of globalization such as professional mobility, health sector
reform, and public concern with the quality of healthcare services have led to
greater interest in nursing regulation. In conjunction with WHO, the ICN has
established a regulation network as both a forum for exchanging ideas,
experience, and expertise in regulatory issues affecting nursing and also as a
source of information and guidance to deal with emerging issues (ICN, n.d.).
Conferences are held at regular intervals, with the most recent, as of this
writing, held in Geneva in May, 2008 (World Health Professions Alliance,
While international and national nursing bodies are focusing on
international standards for nurses, more inclusive movements for
educational harmonization that involve national governments are under way.
One of the most significant is the Bologna process or Bologna accords. The
purpose of this undertaking is to make academic degree standards and
quality assurance standards more comparable and compatible throughout
Europe. The process extends beyond the EU to include some 45 countries
(Zgaga, 2006).
Clearly, further harmonization is required. Academic records or diploma
titles enable European Union (EU) nurses to register and work in any EU
country. Currently, nursing programs that enable nurses to practice in the EU
have been subjected to two European directives regarding the qualifications
of nurses responsible for general care. Directives 77/453/ECC and
89/595/EEC stipulate that a registration program should be at least 3 years
long or 4,600 hours (Zabalegui et al., 2006, p. 115). However, a survey of
nursing education in the EU indicates programs take place in a variety of
universities, colleges, and schools and that curricular and degree structures
vary greatly (National Nursing Research Unit, 2007). Despite these
differences, entrance examinations are not required when nurses migrate.
The Bologna process offers the opportunity to standardize nursing
education, with the bachelors degree as the entry level to the profession,
and masters and doctoral degrees recognized in all EU countries (Zabalegui
et al., 2006). Some European countries have already adopted a three-year
bachelors degree as the criterion for entry to practice. Other countries,
including some in Eastern Europe, are moving toward this standard
(Krzeminska, Belcher, & Hart, 2005; Marrow, 2006).
The Tuning Educational Structures in Europe project, a component of
the Bologna process, builds on previous endeavours to enhance interuniversity cooperation and aims to identify generic and specific
competencies for nursing graduates at bachelors, masters, and doctoral
levels (for additional information on these specific competencies see Gobbi,

2004). Graduates, academic faculty, and employers participated in the

project, which included a method designed to make the different nursing
curricula understandable across countries. The process used by these team
members led to the identification of 30 generic and 40 specific nursing
competences that will serve as a framework for evaluation. Zabalegui et al.
(2006, p. 117) noted that within this new structure, a bachelor in nursing or
nursing science will denote achievement of the specified competencies in an
academic environment.
While the Bologna process directly concerns Europe and its immediate
neighbors, it has generated global attention because harmonization of
nursing in this large geographical area will have worldwide repercussions
(Zabalegui et al., 2006). It has aroused the interest of countries such as
Australia and New Zealand, rival providers of educational services (Australian
Department of Education, Science and Training, 2006; New Zealand, Ministry
of Education 2007), as well as countries in the Far East (Zgaga, 2006).
Schools of nursing in the Philippines, India, and China will need to take
the stipulations of the Bologna process and the competencies identified in
the Tuning project into account if they wish their graduates to be eligible to
work in Europe. Other economic and political partnerships elsewhere in the
world may be interested in participating or developing their own
harmonization projects. While educators in North America may prefer
alternative approaches to nursing education, they will need to address
educational equivalences and differences in nursing education and nursing
qualifications. Careful comparisons between education systems may be
necessary. For example, competencies and hours of instruction or clinical
practice may need to be considered when calculating equivalencies.
Some nursing leaders are uncomfortable with change and struggle with
transforming the system instead of serving as role models. Porter-OGrady
encourages them to make it safe to discuss what nurses can stop doing and
make sure theyre letting go of the right things. He urges them to model
change and to discourage their staff from saying I want to do the most I can
for my patients, because theres no relationship between volume and value.
He believes leaders have to be comfortable with change and with being
vulnerable; they have to be comfortable admitting, I dont know, but I can
find out.Im not sure how well get there but Ill be with you. I wont desert
Burnes Bolton advises nursing leaders to work together during this
crucial time. We have the attention of the federal government and
organizations like the Institute of Healthcare Improvement and the Robert
Wood Johnson Foundation. Our panelists express concern about a leadership
gap and wonder where the next leaders will come from. While new leaders
are emerging, the panelists emphasized they have the responsibility to
mentor future nurse leaders. They know that the more impact they have on
their profession and their colleagues, the more service they can provide to
patients. Its a different way to serve, Porter-OGrady says.
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Trends and Issues in Nursing. (2015). Retrieved from: