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Abstract: More than a a decade ago nurse experts identified information critical for their practice in the 21st century, initiated by the increasing globalization of healthcare and nursing education. Much has happened since then. We know more about the healthcare needs of developing and developed countries, although solutions remain problematic. Although nurses continue to migrate, exaggerating developing country health issues, they are plagued by the variability in how they are educated. For example, some countries prepare nurses in high school, while in other countries nurses are educated in institutions of higher education. Recognizing this variability, nurse leaders have undertaken several efforts to address this variability. The purpose of this article is to highlight several issues associated with global education in general, describe current efforts in nursing and midwifery to strengthen nursing education, and discuss why these efforts are relevant to maternal-child nurses. This information is particularly relevant when one considers the contributions appropriately educated nurses and midwives can make as achieving select United Nations Millennium Development Goals.
More than a decade has passed since Freda (1998) challenged maternal-child nurses to consider what information would be critical for their practice in the 21st century. Her challenge was predicated on increasing globalization of healthcare, including the increasing number of patients from a variety of countries and cultures, an increasing awareness of global health needs, and issues associated with the migration of nurses from and to the United States. She also highlighted global efforts "to improve nursing education...throughout the world" (n.p.).
Much has happened since 1998. It is no longer uncommon for nurses to care for persons from different countries. A concerted effort is underway to address healthcare needs of developing and developed countries, spurred on, in part, by country efforts to address the UN Millennium Development Goals (MDGs) (United Nations, 2000). We now know more about why nurses migrate (Brush, 2008; Callister, Badkar, & Didham, 2010; Kaelin, 2011; Nichols, Davis, & Richardson, 2010; Smith, Fisher, &Mercer, 2011) and about the continued issues associated with their migration (Hancock, 2008). The focus of this article, however, is on the progress made in nursing education.
No discussion of global nursing education efforts is complete without addressing the impact that globalization has on education in general. Current discussions about education make clear that "education has become a business in the globalized world and is seen as both an investment and an export commodity" (Baumann & Blythe, 2008, p. 2). In fact, Stearns (2009) indicates that it is rare for a university or community college in the United States to not be involved in some or many aspects of global education, as significant financial benefits can result from such activities. Transnational education efforts are becoming more common with countries such as Singapore and Malaysia (Mok, 2011), Hong Kong (Shive, 2010), and the United Arab Emerites (Global Higher Education, n.d.) investing in establishing educational hubs. Globalization has contributed to increasingly mobile faculty and students (Vincent-Lancrin, 2009a), a decrease in national oversight (Marginson & van der Wende, 2009), the massification or exponential growth in academic research (Vincent-Lancrin, 2009b), and an increased focus on quality assurance (Lewis, 2009). Lastly, healthcare providers including nurses are becoming acutely aware that we must transform how we educate future providers if we are to influence global health needs (Frenk et al., 2010).
Although general education issues are applicable to nursing education, unique issues also exist. Variability of methods of education, a lack of external programmatic oversight and evaluation, and migration all take their toll on nursing education.
One particularly problematic issue is the variability in methods of education of nurses and midwives. We continue to prepare nurses in secondary schools, hospitals, technical colleges, and universities. Moreover, degree requirements can vary between countries, as they do between the United States and Ireland. Although both countries offer baccalaureate education, the number of weeks of clinical experience as a student is very different: students in Ireland must have 81 weeks of clinical practice during their program, far in excess of what is required in the United States and Canada. In some countries, nurses continue to be educated at the high school level, whereas in a country such as Rwanda, prior to 2007, a student completing 4 years of secondary school education and earning a predetermined overall grade was certified by the Minister of Education as a nurse (Roxburgh, Taylor, and Murebwayire, 2009).
Another issue is the absence or limited availability of nursing programmatic evaluation and oversight by professional organizations such as the National League for Nursing Accrediting Commission and the Commission on Collegiate Nursing Education. The standards developed by these organizations contribute to a general understanding of what comprises nursing education and provide a mechanism by which to determine how well nursing programs meet those standards. When such oversight is not available, the integrity of educational programs can be compromised, exaggerating the presence of an ill-informed workforce. When educational endeavors are driven by the business aspects of education, the possibility of launching "nursing education programs that may be of questionable quality, may be fraudulent, and may exploit students" (Morin, 2011, p. 363) increases. Many countries do not have licensure/regulation processes in place, making pubic assurance of a minimally prepared safe practitioner problematic.
Nurse migration influences nursing education in countries that supply nurses as well as in countries receiving nurses (Hancock, 2008). Experienced and educated nurses may leave the supplying country, resulting in those with less education and experience serving as nurse educators. To address this gap, countries may recruit nurses from other countries. However, ex-patriot nurses may not appreciate culturally specific care required in their new country, thus "undermining practice education environments" (Hancock, 2008, p. 260).
Curricula may be altered so that nurses are prepared to address healthcare needs in receiving countries rather than those of the supplying country. For example, nurses in the Philippines are prepared for export, primarily to the United States; thus, their curriculum may include more information about healthcare needs in the United States than the health needs of people in the Philippines.
Nurses who migrate must learn new cultural values and education systems, and may possibly experience discrimination (Hancock, 2008). Moreover, their knowledge and expertise may not be used appropriately because of regulatory, professional, and language issues. Given the preceding discussion, numerous global issues can influence nursing education.
Globalization has resulted in a world that is interdependent and interconnected, and that challenges us about how best to prepare a knowledgeable workforce for the 21st century to address the increasingly global and international nature of healthcare (Pruitt & Epping-Jordan, 2005; Organization for Economic Co-operation and Development, 2009). Not only do we now recognize the increasing complexity of healthcare, but we also appreciate the increasing diversity of patient populations and explosion of evidence on which to provide care.
Since Freda (1998) wrote her article, national (Front Line Care, 2010; Institute of Medicine [IOM], 2010) and global bodies (Department of Human Resources for Health, World Health Organization [WHO], 2010) now recognize the need to increase the educational level of nurses. In the United States, the need to have a nursing workforce that comprised at least 80% baccalaureate prepared individuals by 2020 was made explicit in the Institute of Medicine's (2010) The Future of Nursing report. Globally, the WHO's Strategic Directions for Strengthening Nursing and Midwifery 2010-2015 (Department of Human Resources for Health, WHO, 2010) stresses the need to prepare competent practitioners.
However, recognizing the need is not sufficient. Providing standards and competencies to guide the education of nurses and midwives is equally important. In an effort to address these acknowledged needs, two efforts are discussed: Global Standards for the Initial Education of Professional Nurses and Midwives (Department of Human Resources for Health, WHO, 2009) and Global Standards for Midwifery Education (International Confederation of Midwives [ICMs], 2010a). These standards are important as globally nurses and midwives are educated differently. For example, in the United States there are two groups of midwives: certified professional midwives and certified nurse midwives. In some countries, midwives and nurses may begin their education and become differentiated after 1 or 2 years of education. In other countries, midwives receive formal education in institutions of higher learning that is distinct from the education preparing nurses and that may have included some basic nursing education.
These standards are intended to "serve as a benchmark for moving education and learning systems forward to produce a common competency-based outcome in an age of increasing globalization" (Department of Human Resources for Health, WHO, 2009, p. 12). They address five areas relevant to nursing education: "programme graduates (outcomes and attributes); programme development (governance, accreditation, infrastructure, partnerships); programme curriculum (design, core curriculum, curriculum partnerships, and student assessment); faculty (academic and clinical, professional development); programme admission (policy and selection, student type and intake)" (Morin, 2011, p. 363). The standards stipulate that education takes place in an institution of higher education, that is, in a university, college, or polytechnic.
To appreciate the significance of these standards, nurses need to understand two important definitions: initial education and professional degree. Initial education is defined as "the planned educational programme that provides a broad and sound foundation for the safe autonomous practice of nursing or midwifery and a basis for continuing professional education" (p. 36). Professional degree is defined as "the first degree offered at the university level" (p. 36). Both definitions are critical to moving forward the use of the standards as well as the methods of education in the global community, as in many countries individuals called nurses received little, if any, formal education about nursing (Department of Human Resources for Health, WHO, 2009). Having more explicit definitions and standards provides nurses in their country with the necessary tools to develop nursing education programs in line with those in other countries.
Although the value of baccalaureate education is being recognized by more countries, such recognition highlights a pressing need: sufficient numbers of appropriately prepared faculty. For example, nurse leaders in Papua, New Guinea, have endorsed baccalaureate education as the basis for preparing nurses in country. Unfortunately, discussions with these nurse leaders reveal that sufficient numbers of faculty prepared beyond the baccalaureate are not available, contributing to a situation in which faculty are trying to prepare practitioners at level beyond which they themselves are prepared. Using the global standards as a guide, nurse leaders in Papua, New Guinea, can argue for increased resources to enhance the level of education of their nurse educators, and to ensure their programs meet established global standards for nursing education.
This set of standards provides more specific guidelines for educating midwives. The developers of these value-based standards make explicit that the standards reflect minimum expectations to have a midwifery program of quality. Developed concurrently with revisions to the Essential Competencies for Basic Midwifery Practice (ICMs, 2010b), these standards can be used to benchmark midwifery practices around the globe. They will be of particular use for individuals in countries:
1. That do not yet have basic midwifery education but want establish such programs to meet country needs for qualified healthcare personnel,
2. With basic midwifery education programs that vary in content and quality who wish to improve and/or standardize their quality,
3. With existing standards for midwifery education who wish to compare the quality of their program to these minimum standards (p. 4).
We can use the standards, which address six major areas (organization and administration; midwifery faculty; student body; curriculum; resources, facilities, and services; and assessment strategies), to help governments, ministers of health, and other policy makers create a well-educated workforce to meet in-country healthcare needs. Both sets of standards recognize the importance of educating nurses and midwives with the necessary knowledge, skills, and attitudes to address healthcare needs within their country. In addition, both stress the importance of embracing the global nature of knowledge, thus challenging nurses and midwives to consider the contextual nature of knowledge as they interact with patients and colleagues from around the world. Although there is considerable similarity between the two documents, the relationship between competencies and standards is made more explicit in the ICM document. Moreover, use of the ICM guidelines is limited to those institutions preparing midwives only, whereas the global standards for the initial education of professional nurses and midwives encompass both groups of healthcare providers.
Why does the education of nurses and midwives have such a critical role in global health discussions? There are several reasons: (1) the critical role of nurses and midwives as the backbone of healthcare globally (Roxburgh, et. al, 2009; UNFPA, 2011); (2) the appreciation nurses and midwives have for practice based on evidence, and (3) the growing concern that two MDGs particularly relevant to women and children will not be achieved by 2015 (Bhutta et al., 2010). All are inextricably related and interdependent.
Nurses are recognized as the backbone of healthcare (IOM, 2010). Increasingly, however, the critical role of educated nurses and midwives in providing care to women and children is being recognized (Roxburgh, et. al, 2009; UNFPA, 2011), driven by abysmal global maternal and infant morbidity and mortality statistics. One needs to consider that "every year approximately 350,000 women die while pregnant or giving birth, up to 2 million newborns die within the first 24 hours of life, and there are 2.6 million stillbirths" (UNFPA, 2011, p. iii). Campbell and colleagues (2008) highlight that attention to quality of care, including increasing the knowledge of healthcare workers, can help achieve two MDGs relevant to maternal child nurses: MDG4 Reduce Child Mortality and MDG5 Improve Maternal Health. Both sets of standards are concrete tools to help increase nurse and midwife knowledge.
The current emphasis on practice based on evidence means we consider all sources of information, including those generated by colleagues around the globe. Siantz and Meleis (2007) argue that by challenging traditional views of nursing, globalization results in the merging of knowledge "that transforms and is transformed by the culture and people with whom we partner" (p. 88S). Such a perspective encourages us to recognize the contributions made by colleagues around the world regarding knowledge generation within a cultural context, including the identification of culturally relevant, evidence-based interventions.
Recent findings support that better patient outcomes are associated with more educated nurses (Aiken et al., 2011; Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Kutney-Lee & Aiken, 2008). These findings are even more critical when one considers possible contributions appropriately educated nurses and midwives can make achieving the United Nations MDGs (United Nations, 2000).
Nurses and midwives have a critical role in assuring that global healthcare needs of women and children are met. Given current global maternal and child morbidity mortality statistics, having well-educated nurses and midwives is paramount. Global standards can provide the necessary guidance to create a knowledgeable workforce of nurses and midwives, and explicate paths for professional advancement. The standards recognize the critical importance of sharing information to help develop the most appropriate, culturally sensitive care. Moreover, the standards acknowledge that knowledge is both local and global, and thus is valuable.
Yet much work remains. We do not yet have data about the usefulness of the standards when interacting with policy makers, nor do we know how many countries are using them to help guide the enhancement of nursing education programs. Ultimately, as nurses and midwives, we are called on to know what resources are available to enhance our collaborations within and across borders to improve the education nurses receive. We must be proactive in ensuring that the care nurses provide is evidence-based and culturally appropriate, and reflects the most comprehensive global perspective.
Institute of Medicine:
International Academic Nursing Alliance:
International Council of Nurses, nursing education network:
Organization for Economic Co-operation and Development:
United Nations Population Fund:
World Health Organization:
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