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The Future of Nursing Education: Ten Trends to Watch

Barbara R. Heller, Marla T. Oros, and Jane Durney-Crowley The millennium has become the metaphor for the extraordinary challenges and opportunities available to the nursing profession and to those academic institutions responsible for preparing the next generation of nurses. Signal change is all around us, defining not only what we teach, but also how we teach our students. Transformations taking place in nursing and nursing education have been driven by major socioeconomic factors, as well as by developments in health care delivery and professional issues unique to nursing. Here are 10 trends to watch, described in terms of their impact on nursing education. 1. Changing Demographics and Increasing Diversity 2. The Technological Explosion 3. Globalization of the World's Economy and Society 4. The Era of the Educated Consumer, Alternative Therapies and Genomics, and Palliative Care. 5. Shift to Population-Based Care and the Increasing Complexity of Patient Care 6. The Cost of Health Care and the Challenge of Managed Care 7. Impact of Health Policy and Regulation 8. The Growing Need for Interdisciplinary Education for Collaborative Practice 9. The Current Nursing Shortage/Opportunities for Lifelong Learning and Workforce Development 10. Significant Advances in Nursing Science and Research

1. Changing Demographics and Increasing Diversity Population shifts in the United States have affected health care priorities as well as the practice of nursing. Due to advances in public health and clinical care, the average life span is increasing rapidly. By 2020, more than 20 percent of the population will be 65 and older, with those over 85 constituting the fastest growing age group. Greater life expectancy of individuals with chronic and acute conditions will challenge the health care system's ability to provide efficient and effective continuing care. Significant increases in the diversity of the population affect the nature and the prevalence of illness and disease, requiring changes in practice that reflect and respect diverse values and beliefs. Disparities in morbidity, mortality, and access to care among population sectors have increased, even as socioeconomic and other factors have led to increased violence and substance abuse. Nursing practice, education, and research must embrace and respond to these changing demographics, and nurses must focus on spiritual health, as well as the physical and psychosocial health of the population. Student demographics are also changing. Ethnic and racial diversity of nursing schools has increased dramatically, creating a rich cultural environment for learning. Students are entering schools of nursing at an older age and are bringing varying college and work experiences, as well as more sophisticated expectations for their education. They are typically employed in full-time careers, and many are raising families, which places constraints on their educational experiences and necessitates greater flexibility in scheduling. Schools of nursing must be prepared to confront the challenges associated with today's more mature student body, and educational methods and policies, curriculum and case materials, clinical practice settings, and research priorities need to value and reflect the diversity of the student body, as well as the population in general. At the same time, schools must focus recruitment efforts on the more traditional, younger student.

2. The Technological Explosion The rapid growth in information technology has already had a radical impact on health care delivery and the

The media and the Internet have facilitated this trend. previously unavailable information is now public information. Along with the potential for rapid disease transmission. Advances in digital technology have increased the applications of telehealth and telemedicine. The Era of the Educated Consumer. such as emerging and reemerging infections. Alternative Therapies and Genomics. Technological advances in the treatment of disease have led to the need for ethical. Nurses of the 21st century need to be skilled in the use of computer technology. and Palliative Care. The electronic medical record will replace traditional documentation systems. the growth of multinational corporations. 3. Through the Internet. . Advances in processing capacity and speed. Technically sophisticated preclinical simulation laboratories will stimulate critical thinking and skill acquisition in a safe and user-friendly environment. With the "death of distance" in the spread of disease and the delivery of health care. developments in image storage and transfer technology. Gene mapping will drive rapid advances in the development of new drugs and the treatment and prevention of disease. The impact of the Human Genome Project and related genetic and cloning research is unparalleled. consumers will be increasingly armed with information previously available only to clinicians. Faster and more flexible access to data and new means of observation and communication are having an impact on how nursing research is conducted. bringing together patient and provider without physical proximity. 4. Dramatic improvements in the accessibility of clinical data across settings and time have improved both outcomes and care of nurses. the fall of communism in Eastern Europe and the Soviet Union. Nursing science needs to address health care issues. including advances in information technology and communications. Nursing education and research must become more internationally focused to disseminate information and benefit from the multicultural experience. Electronic commerce will become routine for transacting health care services and products. international travel and commerce. there are both extraordinary risks and extraordinary benefits. Nanotechnology will introduce new forms of clinical diagnosis and treatment by means of inexpensive handheld biosensors capable of detecting a wide range of diseases from miniscule body specimens. distance learning modalities link students and faculty from different locales and expand the potential for accessible continuing professional education. Globalization of the World's Economy and Society Globalization has been brought about by many factors. and major political changes in Africa and Asia. Alternative Therapies and Genomics Amazing growth is taking place at opposing ends of the technological spectrum. The increased power of the consumer in the patient-provider relationship creates a heightened demand for more sophisticated health education techniques and greater levels of participation by patients in clinical decisions. and there is increased acceptance and demand for alternative and complementary health options. Nurses must be prepared to understand this changed relationship and be skilled in helping patients and families maximize opportunities to manage their health. today's patient is a well-informed consumer who expects to participate in decisions affecting personal and family health care. changes in telecommunications technology. there is potential for dramatic improvements in health due to knowledge transfer between cultures and health care systems. The Educated Consumer Despite some information gaps. the development of interactive user interfaces. informed decision making by patients and families. that result from globalization. With advances in information technology and quality measurement. Consumers are thus becoming more interested and knowledgeable about health promotion as well as disease prevention. and the increased affordability of personal computers have contributed to the explosion of information technology applications. Already. and consumers are asked to play a more active role in health care decision making and management.

The Cost of Health Care and the Challenge of Managed Care Cost of Health Care A concern of businesses and governments for at least 30 years. Patients in inpatient settings are increasingly more acutely ill. The marriage of care with cost requires nursing professionals to have an understanding of practice methods that improve quality. While it is thought that it may unlock behavioral and spiritual components of health and healing heretofore resistant to most conventional medicine. therapeutic conflict. and duration of chronic conditions. alternative medicine holds both promise and peril. Increasingly. Several academic medical centers now have offices of alternative medicine. 6. Despite the fact that more than 40 million Americans lack health care insurance coverage. the cost of health care in the United States has approached 15 percent of the total gross national product. which has the potential to lead to unparalleled ethical questions and conflicts while bringing about critical diagnostic and therapeutic developments. expanded life expectancy has led to increases in the number. total health care spending in this country significantly outstrips that of other developed countries. 5. Greater recognition of the need to ensure comfort and promote dignity is reflected in the now nearly universal promotion of advanced directives. severity. are now likely to be part of well-developed health care systems. spiritual practices. The community has largely become the setting for chronic disease management and prevention. while managing ethical conflicts and questions. up substantially from a decade ago. the voracious demand by consumers for "alternative" or "complementary" therapies to enhance health and healing has begun to influence mainstream health care delivery. These concepts must be incorporated into the nursing curriculum. risks of consumer fraud. New settings for care. Nursing research has the potential to enhance knowledge regarding what constitutes a "healing" therapy.Technological sophistication of the highest order is required for this research. respond to clinical complexity. Western medicine while offering the best of the alternative therapies to their patients. major health systems are seeking ways to provide both traditional. the standard ratio of critical care/specialty beds to general use beds in hospitals today is close to 1:1. The inclusion of nontraditional health care providers may augment the health care team. and the National Institutes of Health recently funded new initiatives dedicated to this field. organ donation. and new forms of care. thereby increasing the complexity of the care provided and managed by clinicians. and lower costs. Thus. Nursing education and practice must expand to include the implications of the emerging therapies from both genetic research and alternative medicine. and their application to specific populations. individuals have joined the debate about health care costs. Providing services for defined groups "covered" by managed care will demand skills and knowledge in clinical epidemiology. including the . such as inpatient and home-based hospice. behavioral science. biostatistics. Many reasons have been suggested. At the low-tech end of the spectrum. and certain health indices lag by a wide margin behind those of other societies. Furthermore. and palliative care for the terminally ill. Managed care and risk-based contracting mechanisms have forced a shift from episodic care with an acute orientation to care management with a focus on population-based outcomes. including pain management. As is true for many trends. A significant gap in the body of scientific knowledge and clinical education with regard to palliative and end-of-life care remains. Shift to Population-Based Care and the Increasing Complexity of Patient Care Rising costs and an aging population have led to new settings and systems of care across the health care continuum. Nurses must demonstrate management skills at both the organizational and patient care levels. and patient noncompliance are real. and support groups and bereavement counseling. and nursing education must prepare graduates for a significant role in these areas. Palliative and End-of-Life Care Technological advancements in the treatment of illness and disease have created new modalities that extend life while challenging traditional ethical and societal values regarding death and dying.

And there is heightened concern about pharmaceutical costs. 7. measure. health promotion. shared responsibility for the Medicaid program and the shift to managed care has resulted in an increased oversight role for the states. reducing the incentives to truly manage care. and bureaucrats about the long-term solvency of both publicly funded programs. States must define. scholars. Impact of Health Policy and Regulation The impact of federal and state health policy and regulation on the practice of nursing cannot be ignored. bringing both opportunities and problems.nurse practitioners and case managers in particular . and assess quality. there is serious concern among economists. Consumers are concerned about quality. Nursing professionals. advanced practice nurses . and promote health. executives. For example. Demand for these lower cost providers has dramatically increased. nursing's influence on policy and regulation has been disproportionately low relative to the breadth of nursing practice and its importance within the health care delivery system. first by corporations for their employees and now by governments. and the growing economic and health disparity between segments of the population. First. However. involving the fields of medicine and economics. Two major trends will have a significant impact on health care delivery. are disappointed by the lack of financing and reimbursement available through managed care organizations for these vital services. not health care professionals. and patients' perceptions of and participation in care. managed care is quickly becoming the dominant reimbursement mechanism for health care providers. Despite the promise for flexible financing that managed care risk was thought to offer. through the Medicare and Medicaid programs. and serve as contractors for corporate entities while enforcing accountability of managed care organizations. by the development of sophisticated new drugs. and advanced nursing practice. Concerns about cost are present in every form of nursing practice. . and their competence and quality in the primary care field have been acknowledged. More research is needed to demonstrate the value to the health care delivery system. the scientific and technologic infrastructure that has led to most of the diagnostic and therapeutic breakthroughs in medicine. the cost of violence and drug addiction.advanced technology available to virtually all residents through academic medical centers. even individuals with health insurance are wary of increased out-of-pocket expenses and noncovered services. Historically. Along with regulation. Second. there will be attempts to shift to less expensive settings and apply market forces to restrain costs. Nursing schools. there will be an increase in state and federal regulation as costs rise and managed care continues to expand. Ethical issues involved in working in an integrated system constrained by economic incentives are being defined more and more by government policy makers. legislators. prevent illness. of health education. Issues surrounding health care are often complex. they affect how work is organized. APNs still confront barriers to direct reimbursement from managed care organizations that lack the knowledge and political will to challenge the traditional medical model. Managed Care and Reimbursement Challenges Within both the public and private sectors. treatment plans for patients. fueled. and professional nursing organizations must more actively contribute to the development of health policy and regulation. as well as the cost effectiveness. Nursing leaders should contribute to the dialogue that defines these issues. in part. who have historically taken the lead in health education and health promotion. Concerns about cost have led to the popularity of managed care options. students must be prepared for a meaningful role in the political arena. and affecting individuals' rights as well as access to health care. nurse practitioners are deterred from being credentialed on provider panels. cultural norms regarding aging and end-of-life. provider contracts are still based on fees for service. and corporations and individual providers are concerned about economic survival. Across the country. Both new regulation and devolution have serious implications for health care delivery and the practice of nursing. Nursing education programs must prepare students at all levels for roles in case management and employment in the managed care environment. Despite recent federal budget surpluses and proposals to expand funding and benefits in Medicare.have benefited greatly by the managed care movement.

as part of the primary care team. and the desire by practicing . in acute care hospitals. including aggressive student recruitment and the initiation of an intense media/marketing campaign. physicians. there has been a heightened awareness of the need for coordinated care and a significant increase in the use of midlevel providers. The Growing Need for Interdisciplinary Education for Collaborative Practice A wide range of knowledge and skills is required to effectively and efficiently manage the comprehensive needs of patients and populations. Teaching methods that incorporate opportunities for interdisciplinary education and collaborative practice are required to prepare nurses for their unique professional role and to understand the role of other disciplines in the care of patients. and the interest of biotechnology. social workers. organizational. and pharmaceutical companies in hiring skilled nursing professionals. the current shortage will almost certainly raise salaries and increase flexibility for nurses. Nurse managers and executives require clinical experience and strong communication skills. and other providers to work together. These include the opportunity to practice in a variety of clinical settings. While the number of male and minority students has been steadily rising. organizational theory. such as APNs. While interdisciplinary and collaborative practice is still not the norm. Rapidly evolving technology. Nursing schools are called on to expand their core and continuing education programs to address these needs. and the emergence of new diseases are all factors contributing to the increased need for a strong emphasis on critical thinking and lifelong learning among professional nurses. As the age of entering students rises.and longterm solutions that address the nursing shortage. The public image of the nursing role must be revitalized to change outdated perceptions. The current shortage is judged to be deeper than past shortages and probably more resistant to short-term economic strategies that have worked before. also affecting supply. particularly in acute and long-term care settings. nurse practitioners. The health care delivery system of the future will rely on teams of nurses. With care management a critical component in health care delivery." which contributes to the lack of new individuals entering the field. nurses of the "baby boom" generation are beginning to retire. as in the past. the dramatic increase in opportunities for APNs. dentists." versus a "profession. the imperative to retain nurses in active practice over longer careers. the need for managerial and executive talent. nursing management is too often found to be lacking in fundamental decision science and fiscal knowledge. and fiscal challenges faced by the health care industry has not gone unrecognized. as well as business acumen and knowledge of financial and personnel management. interdisciplinary approaches have been shown to be highly effective for improving clinical outcomes and reducing cost. The Current Nursing Shortage/Opportunities for Lifelong Learning and Workforce Development Nursing shortages have a negative impact on patient care and are costly to the health care industry. long-term care facilities. new careers in care management and case management. However. For example. With the nursing labor budget constituting a significant proportion of total spending. and home care agencies. information technology. increasing clinical complexity in many patient care settings. nurses must demonstrate leadership and competence in interdisciplinary and collaborative practice for continuous quality improvement. the number of years of practice decreases. A significant nursing shortage exists today. Nursing education must partner with the health care industry to develop innovative short. and there is a lingering perception of nursing as a "trade. It results from many factors. their ranks are still underrepresented. The need for more sophisticated nursing management and leadership to respond to the clinical. Team-based. 9. prepared to work competently alongside their business colleagues. and cost overruns. women today have numerous career opportunities. new clinical roles. A great need exists for educational support for experienced nurses to be developed into nurse executives. advances in treatment.8. Other recent advances in the profession and the health care industry are likely to have a positive impact on recruitment. pharmacists. and negotiation. Further.

At the dawn of the 21st century and the long-awaited new millennium. although graduate degrees in nursing have become more common. and disease prevention. MHA. and. EdD. About the Authors Barbara R. Jane Durney-Crowley. Heller. Schools of nursing have many of the core resources needed to deliver continuing professional education and can provide appropriate courses efficiently and effectively. and lower costs. Baltimore. an explosion of technology.. in addition to a myriad of everyday challenges. . School of Nursing. 1992). Most studies concern health behaviors. Affiliation with schools by nurses in active practice may lead to an increase in enrollment for advanced degrees. University of Maryland. Operations and Culture. nurse educators face a rapidly changing health care landscape. University of Maryland. Cincinnati. doctorally prepared nursing professionals are not being produced in large enough numbers to meet the growing need. is assistant dean for clinical practices and services. As we position ourselves to meet today's challenges and tomorrow's. especially of the most vulnerable populations.a member of the Board of Visitors. especially those affiliated with academic health centers. is dean and professor at the School of Nursing. MS. Significant Advances in Nursing Science and Research Nursing research is an integral part of the scientific enterprise of improving the nation's health. the challenges associated with advancing the research agenda in nursing are complex and varied. Ohio. However. She is serving her second term as a member of the National League for Nursing Board of Governors. Oros. School of Nursing. Catholic Healthcare Partners. The growing body of nursing research provides a scientific basis for patient care and should be regularly used by the nation's 2.nurses to move up the economic ladder lead to the demand for continuing education and career mobility and development. treatment. Marla T. there is a need for enhanced mentorship for new researchers to strengthen skills and capacity to conduct meaningful nursing research.5 million nurses. Health care and health-related organizations may serve as institutional partners in sponsoring such program offerings. to address these challenges and enhance the research contributions of nursing scholars. symptom management. To quote Peter Drucker in Managing for the Future. RN. and the globalization of health care. University of Maryland. 10. Research is conducted to improve patient outcomes and promote the health and well-being of communities. it is only necessary to clearly interpret what has already happened and then project forward the likely consequences of those happenings" (Truman Talley Books. shifting student and patient demographics. In addition. and the improvement of patients' and families' experiences with illness. increase participation. which would contribute to their relevance. Significant opportunities exist for schools of nursing. we must understand the drivers affecting nursing. is Executive Vice President. "It is not necessary to be clairvoyant to know the future. Nursing research and scholarship has received significant funding by public and private agencies in the last decade and is increasingly recognized as an independent body of knowledge. RN. Schools of nursing are not sufficiently focused on the scholarship and science of nursing as top priorities. FAAN. RN.

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