The Future of Nursing Education: Heading for a Major Crisis
Submitted by Rebecca E. Przywara, BSN Student Nyack College, NY & Maureen Kroning RN EdD, Associate Professor at Nyack College, NY
Nursing as a practice and profession has experienced significant changes over the years. For instance, in the 1800s nurses were expected to be subservient to doctors. Just hear what the doctor who gave Springfield Hospital’s first nursing graduation address: "Every nurse must remember that it is the attending physician's business to make a diagnosis of disease and hence that she should never hazard an opinion herself, under any circumstances." (Dr. Hooker, Springfield Hospital Annual Report, 1894). It would be interesting to know what the nursing faculty were thinking when they heard those words. Thankfully nurses during that era did not take the doctor’s advice and remained dedicated to advance and advocate for the profession of nursing.
Around the same time that Springfield Hospital’s first nursing graduating class were listening to their graduation address, Florence Nightingale along with other nurse advocates, were making incredible strides to implement nursing education. After the Crimean War, Florence Nightingale recognized and introduced the need for formal nursing education but the education was limited to basic nursing knowledge and skills. As a result of the Women’s Rights Movement in the 1900s, the idea of nursing as a profession evolved into a reality. As society’s healthcare needs changed, nursing education had to change to meet those needs. There were however, challenges each century faced when trying to ensure nursing education met society’s needs and today, the challenges faced are heading right for a major crisis.
Nursing Education in the 1800s
During the 1800s nursing was considered a calling which required little education. Nurses were taught basic skills to keep patients comfortable during their stay in the hospital. In 1860, Florence Nightingale developed and opened the first scientific based nursing school in London at St. Thomas Hospital (Berman 2012). During this time, the demands on nursing were growing more expansive. According to the American Association for the History of Nursing, in the mid to late 1800s: hospitals that trained nurses, lacked consistent standards, required one year training then two years training and eventually three years training which consisted not only of caring for patients but the nurse was responsible for food service, laundry and cleaning as well as caring for the patient’s healthcare needs. Responding to the need for nursing care during the Civil War, the American Medical Association (AMA) formed a committee in 1869 recommending that all large hospitals in the United States (US) should implement a nursing school with emphasis on a union between religious affiliations and nursing to care for the sick (Ellis & Hartley, 2012).
In the U.S. in 1899, Columbia University’s Teachers College offered the first formal nursing education program in New York which still exists today (Teachers College Columbia University). Nursing education now required nursing students to demonstrate proficiency and competency prior to delivering care to patients. In the late 1880s and 1890s, a women’s movement, created a surge of women volunteering outside of their homes which included caring for the sick and injured (History, Art & Archives). At this time, nursing began to flourish and grow well into the 20th century.
Nursing Education in the 1900s
According the U.S. Department of Labor, on June 5, 1920 a federal mandate was passed to: “formulate standards and policies which shall promote the welfare of wage-earning women, improve their working conditions, increase their efficiency, and advance their opportunities for profitable employment.” Since that time, this same mandate worked to identify and address work related issues important to women (U.S. Determent of Labor). The women’s right movement began changing the culture of the workplace and society’s viewpoint on what careers women could pursue and with that the face of nursing began changing dramatically. Nursing began developing into a respected profession which required nurses to know a wealth of information, be skilled in implementing new, life-saving procedures, and be responsible for assessing, diagnosing, and treating patients’ health conditions (Fairman 2008). As the demands on nurses grew, the education requirements also evolved and nurses had to be educated beyond the simple basic skills and knowledge prior to caring for patient’s lives and had to adhere to standards of care.
College based nursing programs were recommended during the early 1900s by the American Society of Superintendents of Hospital Training Schools, later re-named National League of Nurse Education and Columbia University’s Teachers College, recognized a need for both academic and clinical experience and supported the need for nursing specialties such as public health nursing (Judd, 2010). By 1921, 48 states passed nursing licensure act, North Carolina being the first to do so in 1903 (Egenes, 2009). In the 1920s and 1930s hospitals were faced with increasingly complex patients and thus looked towards the nursing profession to expand their educational preparation of nurses (Judd). By 1950, nursing was considered a major occupation and by 1960, approximately 172 Bachelorette nursing programs were in existence (Judd). Numerous nurse leaders were instrumental in advocating and advancing both nursing education and the profession of nursing.
Lillian Wald, Mary Brewster, Linda Rogers, Mary Sewell Gardner, Lavinia Lloyd Dock were among nurse leaders that united to advocate for: educational standards, legal controls to prevent existence of poor nursing programs, promote nursing educational reform for college based nursing programs and the promotion of diversified clinical experiences (Judd). After the 1980s, nurses expanded their roles to include facilities outside of the acute care hospital setting which required changes in nursing education (Fairman 2008). In 1965, the ANA’s Committee on Nursing Education recommended nursing education would have a minimum of four years at a college or university level unless the student wanted technical skills then the education could take place in a community college earning an associate’s degree.
Nursing Education in the 21st Century
As the role and responsibly of nurses evolved to include guidelines, regulations and standards of care so did the education requirements which required nursing programs to achieve accreditation and nurses to receive licensure to care for patients. According to the American Nurses Association (ANA), to become a Registered Nurse (RN) one must graduate from one of the following nursing educational programs: diploma, associate, bachelor or a less common one, a master's degree program and then must pass the National Council Licensure Exam (NCLEX). A Registered Nurse can choose which degree program they wish but with each higher level of education brings increased privilege and responsibility (Berman 2012).
The Committee on Nursing Education, a committee branch of the ANA, envisioned that there would be two separate divisions of nurses, technical and professional (Donley & Flaherty). In 2002, the American Association of Critical-Care Nurses (AACN) campaigned for associate level nursing degree programs to be shut down and be denied eligibility to obtain an RN licensure and promoted along with the Commission on Collegiate Nursing Education (CCNE) that by 2015 there would be clinical nurse leader and Doctorate of Nursing Practice (DNP) degrees to enter specialized advanced practice (Donley & Flaherty).
According to AACN cited by Donley & Flaherty, the majority of colleges and universities offer specialized nursing programs at both the bachelor’s and master’s levels. Today, many hospitals require RNs to have at least a Bachelor’s of Science in Nursing (BSN) to work in their institution. Consequently, many hospitals are requiring that nurses who already have an associate’s degree return to school in order to complete their bachelor’s degrees in nursing (Berman 2012).
While a bachelor’s degree is clearly beneficial, a master’s degree offers a number of further benefits to the nurse looking for higher education and advancement in the workplace. “A number of policy documents on master’s level education both in nursing and other disciplines identify management, communication and leadership capabilities as core outcomes of the degree” (Drennan 2012). Particularly for nurses seeking leadership roles, a master’s degree provides opportunities for greater autonomy and management positions that would have been unthinkable only a few decades before. Advanced degrees such as Nurse practitioner (NP) programs are common today and require a high level of critical thinking and problem solving skills. Additionally, a higher degree in nursing such as a master’s provides opportunity for research roles, which is relevant to nursing care as the demand for new responses to familiar diseases escalates (Drennan 2012). The Robert Wood Foundation and the Institute of Medicine recommend to increase RN with BSN degrees to 80% over the next ten years and the need for doctorate prepared nurses is even more critical today (Feeg & Nickitas, 2011). According to Ellenbecker (2014) obtaining doctorate-level degree will meet the role of future nurse educators and maintain a high standard of healthcare delivery. Even with the recommendations for higher degrees in nursing there are challenges that need to be addressed for schools of nursing today.
Present and Future Challenges: A Critical Issue
As an Associate Professor of Nursing there are many challenges to educating our future nurses. The first challenge is finding qualified faculty to teach the knowledge and skills required to train future nurses. Nursing colleges and universities prefer faculty to have a doctorate degree, showing advanced knowledge in their field of study. However, according to Feeg & Nickitas (2011) there are less than 1% of nurses with a doctoral degree and this can cripple the nations’ nursing workforce as nursing faculty retire and leave academia leaving nurses less prepared to care for patients. More nurses need to return to school to obtain higher degrees in order to meet our futures healthcare needs. This challenge is fast becoming a major crisis in nursing education.
The American Association of Colleges of Nursing (2015) provides a collaborative report compiled by healthcare experts to include current and projected nursing indicators and critical issues facing the profession of nursing. The critical issues included are:
• 55% of the RN workforce is 50 or older.
• More than one million nurses will reach retirement age in the next 10-15 years.
• The Future of Nursing report calls for increasing BSN degree nurses to 80% which falls short today with only 55% BSN prepared.
• The U.S nursing shortage is projected to grow to 260,000 RNs by 2025 due to the rapidly aging nursing workforce.
• The average age of the RN will increase, large numbers of nurses will retire and the demand for RN will increase during the latter half of the next decade.
• More than 19,400 RN vacancies exist in long term care settings.
• As of 2007, there were 116,000 open positions in hospitals bringing the RN vacancies to 135,000, a vacancy rate of 8.1%.
• An estimated 30,000 additional nurses need to graduate yearly to meet the nations’ healthcare needs, extending 30% over the present number of nursing graduates.
• The 2.6% increase enrollment of BSN programs is not sufficient to meet the projected demands for nursing care.
• 32 million Americans will gain access to healthcare due to The Affordable Care Act, which leads to the need for greater numbers of RNs and advanced practice nurses.
• There is a shortage of nursing school faculty which impacts nursing programs enrollments.
• A shortage of nursing school faculty are restricting nursing program enrollments.
• 75% of nurses believe the nursing shortage presents a major problem to quality of nursing care and the amount of time nurses spend with their patients.
• Nurses view the shortage of nursing to be a catalyst of increased stress on nurses and lowering quality of care causing more nurses to leave the profession.
• Nurses report greater job dissatisfaction and emotional exhausting when caring for increased patients.
• The limited number of nurses with higher degrees affects both quality and patient outcomes.
Training nursing students in a variety of healthcare settings can also be a challenge. This is a result of multiple factors such as: limited number healthcare institutions, many nursing schools in certain areas requesting clinical placement in the same healthcare institutions and the RNs workload demands make it often difficult to mentor and educate students. There exist critical issues facing nursing education today which is predicted to only get worse in the future unless strategies are implemented sooner than later. Effective nursing leadership will be instrumental in forming affiliations and addressing the challenges nursing education faces today and in the future.
Addressing the Challenges
There are strategies that can address many of the challenges faced by nursing education today such as forming strategic partnerships between nursing schools and healthcare institutions. For instance, the development of educational units were staff nurses work alongside undergraduate nurses to care for patients has been an effective strategy to both help educate our future nurses and to help unit nurses meet the increased demands of patient care. These partnerships are also ensuring clinical placement of nursing students and helping the healthcare facility to recruit students after they graduate. This allows students to have an opportunity, while in their clinical placement, to learn the healthcare institutions policies and procedures, documentation requirements and understanding the culture of the facility. By implementing innovative strategies to address some of the challenges faced by nursing education both healthcare facilities and students can benefit. However, efficient funding is critical in meeting many of today’s and future nursing education challenges.
Nursing education needs to seek innovative ways to receive financial funding to stay current in nursing practice, to be able to attend educational conferences on best-practice approaches to teaching and learning in nursing education, stay current with healthcare technology advances and to ensure a variety of clinical experience for students in the many healthcare settings patient care is provided. The fast paced healthcare environment requires that nursing students are provided with critical thinking skills and knowledge to safely care for patients. Therefore, seeking out opportunities such as grants and public and private funding can help meet these challenges faced by nursing education.
NursingCAS, the country’s centralized application service for RNs, has included graduate programs and is helping to fill vacant faculty positions and maximize nursing schools educational capacity (AACN). Robert Wood Johnson Foundation describes that forming effective partnerships are essential in addressing both nursing and nurse faculty shortages (AACN). According to AACN, in 2009, both academic leaders and those of healthcare from 47 states collaborated in Baltimore to identify and create strategic solutions to critical issues such as: the nursing shortage, best practices, resource alignment, policy and regulations and increasing nursing school faculty and student capacity. There are also many federal and statewide initiatives such as loan forgiveness programs that help to address the RN and nurse faculty shortage. These programs are designed to help pay off student loans for the student’s agreement to work as a nurse faculty for a specified number of years. Developing a greater number of public-private partnerships, partnership between nursing schools and the healthcare institutions, scheduling flexible educational classes, increasing online courses, providing tuition reimbursement and multimedia initiatives to promote careers in nursing and increase nursing school enrollment at both the undergraduate and graduate levels. Nursing programs need to offer graduate level nursing programs and provide salaries comparable to other professional leadership positions in order to recruit and retain competent faculty to educate our future nurses.
Nursing as a profession has evolved and changed over the decades to meet the healthcare needs of society. In meeting society’s needs nursing education has had to design programs to ensure nurses learn the skills necessary to provide safe, quality care to patients. Since Florence Nightingale first established a training school for nurses in the late 1800s, nursing schools have rapidly evolved to incorporate not only training in knowledge and skills, but also, and arguably more importantly, instruction in critical thinking, problem solving, leadership roles, and management tactics. The increased responsibility of nurses today must also be coupled with greater education in order to ensure patients receive quality care. It has been shown “that time and experience are necessary to move along the continuum of novice to expert” when it comes to effective delivery of healthcare (Fisher 2012). With the profession of nursing striving to offer higher degrees such as bachelor’s, master’s, and doctorate degrees, nursing continues to advocate for the needs of society and for the respect and credibility the profession has had since the very beginning. As new technologies are developed, new cures discovered, and new challenges encountered, nursing practice and education will continue to successfully adapt, as it has in the past, in order to meet and surpass the manifold demands of an ever-changing healthcare landscape in the campaign to provide safe, effective, and quality care to all patients. Collaborative strategic partnerships, innovative strategies, advocating for the advancement for both the profession of nursing and quality patients care will help meet the critical issues faced by nursing today and predicated in the future.
American Association of Colleges of Nursing (2015). Nursing Shortage.
American Association for the History of Nursing. Major Events in Nursing and Nursing Education: Part One 1872 thru the Great Depression, p. 1-6.
American Nurses Association. Nursing Education.
Berman, A., & Snyder, S. (2012). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice 9th Ed. Upper Saddle River, New Jersey: Pearson Education, Inc.
Department of Health & Human Services (2010). The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses.
Donley, R. & Flaherty, M. (2008). Revisiting the American Nurses Association’s First Position on Education for Nurses: A Comparative Analysis of the First and Second Position Statements on The Education of Nurses. The Online Journal of Issues in Nursing, 13(2).
Drennan, J. (January 1, 2012) Masters in nursing degrees: an evaluation of management and leadership outcomes using a retrospective pre-test design. Journal of Nursing Management, 20.
Egenes, K. ( 2009 ). History of Nursing. In ORoux, G & Hastead, J. Issues and Trends in Nursing Essential Knowledge for Today and Tomorrow. (p.1-26). Jones and Barlette Learning
Ellenbecker, C. (July 1, 2014). BS-PhD Programs in Nursing: Where Are We Now? Nursing Education Perspectives, 35 (4).
Ellis, J. & Hartley (2012). Nursing in Today’s World. Trends, Issues and Management. 10th edition. Wolters Kluwer/Lippinoctt Williams & Wilkins.
Fairman, J. (March 1, 2008). Context and Contingency in the History of Post World War II Nursing Scholarship in the United States. Journal of Nursing, 40 (1).
Feeg, V & Nickitas, D. (2011). Doubling the Number of Nurses With a Doctorate by 2020: Predicating the Right Number or Getting it Right? Nursing Economics, 29(3) 109-125.
Fisher, M. (January 1, 2014). A Comparison of Professional Value Development Among Pre-Licensure Nursing Students in Associate Degree, Diploma, and Bachelor of Science in Nursing Programs. Nursing Education Perspectives, 34 (1).
History, Arts and Archives (website)
Judd, D. ( 2010 ). A New Century Brings Novel Ideas & Social Concerns. Jones & Bartlett Publishers.
Teachers College Columbia University. Nursing Education.
United States Department of Labor (website)