Trends and Future Directions in Harmonizing Nursing Education

Internationally

Nurses have existed in many cultures since ancient times (Sapountzi-Krepia, 2004). In Europe and
North America, modern nursing developed in the mid 19th century and spread to much of the world
through the globalizing mechanisms of warfare, colonialism, and missionary activities (Basuray, 1997;
Nestell, 1998). The roots of nursing in the Middle East, however, can be traced even further back, to
the Islamic Period (570-632 AD) and to Rufaida Al-Asalmiya, the first Muslim nurse (Miller-Rosser,
Chapman, & Francis, 2000). 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. For example, until recent years, all nursing
education in the Soviet Union and the Eastern Bloc occurred exclusively at the secondary school level
and was subordinate to medicine (Jones, 1997). In other countries, professional education was
increasingly taught at the tertiary level, but curricula content and program length varied.

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 Development's (OECD's) 30 member countries
(listed in the Table 1 ) 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). Further work in this
area is important and necessary.

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, 2008).

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 bachelor's
degree as the entry level to the profession, and master's and doctoral degrees recognized in all EU
countries (Zabalegui et al., 2006). Some European countries have already adopted a three-year
bachelor's 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 inter-university cooperation and aims to identify generic and specific
competencies for nursing graduates at bachelor's, master's, 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