ZHAN Lin

（Loewenberg College of Nursing,University of Memphis,TN 38152,USA）

【國際護理論壇】

編者按：

從20世紀20年代至今，美國護理教育的層次和類型都有了較大的轉(zhuǎn)變。為了適應(yīng)護理教育的變化和日益增長的醫(yī)療保健需要，讓護理畢業(yè)生的能力滿足“better health care,better population health,and cost effectiveness”等目標，美國護理教育在受到了較多沖擊的同時，也相應(yīng)做出了有針對性的調(diào)整。為了更好地了解與借鑒美國護理教育的發(fā)展與轉(zhuǎn)變，本刊名譽主編、美國護理科學(xué)院院士、孟菲斯大學(xué)魯文貝格護理學(xué)院院長、終身教授、護理學(xué)博士詹林教授撰寫了專題論文，通過對美國護理教育歷史的回顧，從最初的實踐、學(xué)歷教育到現(xiàn)在大量的護理專業(yè)型/學(xué)術(shù)型博士，提出學(xué)術(shù)性護理的概念，接著論述了護理學(xué)術(shù)的影響與變革、護理學(xué)術(shù)的職責與認證標準、不同層級護理學(xué)術(shù)核心課程設(shè)置及革新等。從護理教育課程設(shè)置的變革、高等教育認證、教學(xué)方法轉(zhuǎn)變等角度介紹美國護理教育的轉(zhuǎn)型和變化，旨在引發(fā)護理同仁針對護理教育“如何轉(zhuǎn)變以更好地適應(yīng)臨床需要”的思考與討論，歡迎廣大讀者就該主題撰稿探討。投稿方式為登錄護理學(xué)報網(wǎng)站在線投稿，文題后加括號注明“討論”二字。

Transforming Nursing Education:Leading a Way,and Advancing Health

ZHAN Lin

（Loewenberg College of Nursing,University of Memphis,TN 38152,USA）

American Nursing education has been significantly transformed in both types and levels of nursing educational programs in the past decades.For the purpose of discussion and communication with nursing educators and managers in China on how to enhance academic nursing education,the study present sums up the changes and expansions of the transformation and impact of the academic nursing in the United States; the responsibility and accreditation standards of academic nursing; the reforms and essentials of curriculum in different levels of academic nursing.

academic nursing;transformation;accreditation standards;curriculum

Nursing education in the United States has been significantly transformed.Historical transformation has showed changes and expansions of the types and levels of nursing educational programs,from practical or diploma schools to doctoral education.In the early 1900,there were practical,diploma or nighting schools.Between 1920s and 1930s,the Baccalaureate degree in Nursing(BSN)and post-graduate programs were offered while some nurses pursued available doctoral degree in education. In the 1940s and 1950s, there were Associate degree in nursing(ADN),Master’s Science degree in Nursing(MSN),and Doctoral degree in nursing.Since 1960s,nursing education has expanded to include a PhD degree in nursing,Doctorate in Nursing Science(DNS),and recently,Doctoral degree in nursing practice(DNP).To date,of 3 million nurses in the USA,55%have a BSN degree.Concurrently,doctoral programs in nursing have grown significantly. According to American Association of Colleges of Nursing (AACN,2013),in 2006,there were 20 DNP programs and 103 PhD programs in nursing.In the year of 2012,there were 217 DNP programs and 131 PhD programs in nursing.

1 TransformationandImpactofAcademic Nursing

The purpose of academic nursing is to prepare graduates that are qualified and competent to meet ever-changing healthcare needs.Increasing complexity of healthcare,advanced science and technology,aging and diversifying populations,existing health disparities,and emerging threat of global health issues,all require academic nursing to be responsive,proactive,and nimble to serve interests of the community,healthcare,and health of the public[1].

Academic nursing therefore needs to integrate new and essential knowledge in curriculum such as gerontology,management of chronic illnesses,home and community-based care,person and environment interaction,epidemiology,and genetics and genomics.Values and ethics in healthcare are taught to prepare graduates for being patient-family centered and being advocates for patients and their families.To prepare nursing students with advocacy skills, courses in poli tics,economics,ethics and assertiveness are designed and implemented.Course contents related to continuity of and transitional care and global health are integrated. To promote health for all, nursing students must learn how to attend and care for vulnerable populations[2].

2 Responsibility and Accreditation Standards of Academic Nursing

Academic nursing is part of efforts to help reach the national goals termed “Trip Aims” that include better health care,better population health,and cost effectiveness[3].Better quality of care requires health providers to make concerted efforts for patient safety,care effectiveness,patient-centeredness,timeliness,efficiency,and equity.Better population health means to improve overall health outcomes for aging and diverse populations,to manage patient chronic illnesses,to reduce health disparities,and to help aging population live longer and live better while to find ways to reduce cost and healthcare waste.Most importantly,health care providers must improve care quality,improve patient experience,and improve efficiency(USA Center for Medical Services,2014).Healthcare delivery has been transformed to support teamwork,collaboration,delegation and inter-professional education(IPE)for inter-professional practice(IPP).Caring,compassion, and therapeutic communication are emphasized including understanding cultural differences in care and appreciating different languages.

These changes have an impact on academic nursing.Major impacts are to integrate knowledge in teamwork,collaboration,health education,primary care and ambulatory care with family/community focus,and“alternative” therapies with nursing curriculum,design inter-professional education,use competency-based clinical education,integrate simulation and technology,create seamless educational pathways, use conceptbased approaches,design self-paced and self-directed programs,increase flexible and reduce rigidity,and use service learning to meet community needs.

Academic nursing is part of higher education.Higher education has increasing responsibility and accountability to ensure high quality teaching,rigorous research,and accessible and affordable higher education to students.Student success,from recruitment,retention,progression,to degree completion,is placed in the center of strategic thinking in higher education while advanced technology enables higher education to use digital educational delivery and modules to maximize accessibility of higher quality education to students.

Nursing is an applied science.How to prepare graduates to think and act like a nurse in real world prompts nursing to use simulation.Simulation framework is used to guide use of simulation in nursing to cultivate clinical reasoning and critical thinking, to conduct self-reflection in patient situations,to understand and identify therapeutic interventions in complex patient situations for safety and quality care, and to help build students’confidence when they go to clinic.Simulation has proven to be effective in clinical de-velopment of nurses.It provides a safe zone to keep student engaged,to learn real skills,and to apply theoretical knowledge.As well,nursing faculty is challenged to learn how to integrate simulation in teaching and practice.

Academic nursing is held responsible and accountable to meet accreditation standards.American Commission of Collegiate Nursing Education (CCNE)is a nationally recognized nursing accreditation agency established in 1998 by vote of the American Association of Colleges of Nursing memberships(Nursing Deans and Directors).The CCNE’s accreditation scope includes baccalaureate and graduate nursing education programs.There are four standards to evaluate quality of the nursing program,including 1)program quality I:mission and governance;2)program quality II:institutional commitment and resources;3)program quality III:curriculum and teaching-learning practices;and 4)program effectiveness:program outcomes[4].Program outcomes are measured by student outcomes,faculty outcomes,and program outcomes to serve the interest of the community.For example,the nursing program is assessed if it is in line with interests of the community.Quite often,each school/college may have advisory board consisting community major stakeholders to advise the school/college.Student outcomes involve enrollment growth,retention and progression rates,graduation rates,employment rates,graduates pursuing advanced studies(lifelong learning)and career advancement.Faculty outcomes involve teaching effectiveness,research productivity,professional service,and continuing development.

3 Reforms and Essentials of Curriculum in Different levels of Academic Nursing

Nursing Curriculum Program Outcomes

●Patient-centered Care(IOM,QSEN,AACN,Value)

●Clinical Reasoning and Judgment(AACN)

●Evidence-based Practice(IOM,QSEN,AACN)

●Inter-professional Collaboration(IOM,QSEN,AACN)

●Safety and Quality(IOM,QSEN,AACN)

●Health Promotion(AACN)

●Human Diversity and Cultural Sensitivity(AACN,Value)

●Professionalism(AACN,Value)

●Information Management and Patient Care Technology(IOM,QSEN,AACN)

●Communication(IOM,QSEN)

BSN curriculum reform

●Design Gerontology Practicum Course

●Design Nursing Profession Seminar

●Flip flop Mental Healthamp;Community Health courses

●Design Transition into Practice Course

●Integrate service learning

Academic-Practice Partnerships

●Nurse Residency Programs

●Dedicated Educational Units

●Clinical Preceptors/Educators

●Endowed Professorships

●Innovation

●Collaborative research@bedside and/or system levels

●Quality sustainability

Students Practice readiness Clinical Knowledge

●Technical Skills

●Clinical Reasoning

●Therapeutic Communication

●Professionalism

●Management of Responsibilities

BSN Essentials[5]

●Liberal education

●Organizational and system leadership for quality care and patient safety

●Scholarship for evidence based practice

●Information managementamp;application of patient care technology

●Healthcare policy,finance,amp;regulatory environment

●Inter-professional communicationamp;collaboration for improving patient health outcomes

●Clinical preventionamp;population health

●Professionalismamp;professional values

●Generalist practice at the BSN level

MSN essentials[6]

●Sciencesamp;Humanities

●Organizationalamp;System Leadership

●Quality Improvementamp;Safety

●Translatingamp; Integrating Scholarship into Practice

●Informaticsamp;Healthcare Technologies

●Health Policyamp;Advocacy

●Inter-professional collaboration for improving outcomes

●Clinical interventionamp;population health

● Master’s-level nursing practice

DNP Essentials[7]

●Scientific underpinning for practice

●Organizationalamp;system leadership for quality improvement and system thinking

●Clinical scholarship and analytic methods for evidence based practice

●Information system/technology and patient care technology for improvement and transforming healthcare

●Healthcare policy for advocacy in health care

●Inter-professional collaboration to improve patient and population health outcomes

●Clinical intervention and population health for improving nation’s health

●Advanced nursing practice

In 2010,after a decade of studies,the Institute of Medicine(IOM)issued the landmark study Future of Nursing:Leading a way,advancing health[8].The IOM recommended that nurses be better educated, play a major role in transforming nation’s healthcare,designing seamless educational pathways to advance nursing education,and building better data to know types of workforce and needed knowledge that guide nursing practice[9].

Reference

[1]Buerhaus,P,Auerbach D I,Staiqer D O.The Recent Surge in Nurse Employment:Causes and Implications[J].Health Aff(Millwood),2009,28(4):657-668.

[2]Health Resourceamp;Services Administration.Shortage Designation[EB/OL].[2016-11-18].https://bhw.hrsa.gov/shortagedesignation.

[3]Centers for Medicareamp;Medicaid Services.Health Care Innovation Challenge[EB/OL].(2011-11-14)[2016-11-18].https://innovation.cms.gov/files/x/health-care-innovationchallenge-funding-opportunity-announcement.pdf.

[4]Commission on Collegiate Nursing Education.Standards for Accreditation of Baccalaureate and Graduate Nursing Education[EB/OL].(2013-10-01)[2016-11-18].http://www.aacn.nche.edu/ccne-accreditation/Standards-Amended-2013.pdf.

[5]American Association of Colleges of Nursing.The Essentials of baccalaureate Education for Professional Nursing Practice[EB/OL].(2008-10-20)[2016-11-18].http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf.

[6]American Association of Colleges of Nursing.The Essentials of Master’s Education in Nursing[EB/OL].(2011-03-21)[2016-11-18].http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf.

[7]American Association of Colleges of Nursing.The Essentials of Doctoral Education for Advanced Practice[EB/OL].(2006-10-01)[2016-11-18].http://www.aacn.nche.edu/dnp/Essentials.pdf.

[8]Institute of Medicine.Future of Nursing:Leading change,Advancing Health.Author[EB/OL].(2010-10-05)[2016-11-18].http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.

[9]Robert Wood Johnson Foundation.Nursing Research Network Products:New Frontiers in Health Workforce Research:Rethinking the Data Infrastructure[EB/OL].(2010-10-14)[2016-11-18].http://thefutureofnursing.org/nursingResearch-Network9.

[本文編輯：方玉桂 王 影]

護理教育轉(zhuǎn)型：引領(lǐng)方向，倡導(dǎo)健康

詹 林
（孟菲斯大學(xué)魯文貝格護理學(xué)院，孟菲斯 38152，美國）

美國學(xué)術(shù)性護理的類型和水平，從最初的實踐、學(xué)歷教育到現(xiàn)在大量的護理專業(yè)型/學(xué)術(shù)型博士。為了與中國護理教育者和管理者加強學(xué)術(shù)性護理的討論和交流，筆者總結(jié)了美國學(xué)術(shù)性護理的變化和擴展以及帶來的沖擊和影響；學(xué)術(shù)性護理的責任和認證標準；不同層次的護理教育課程的要點。（1）美國護理教育轉(zhuǎn)型的變化和擴展以及帶來的沖擊和影響。隨著越來越復(fù)雜的醫(yī)療需求，先進科學(xué)和技術(shù)的出現(xiàn)，人口老齡化和多樣化，現(xiàn)有的衛(wèi)生差距和新出現(xiàn)的全球衛(wèi)生問題的威脅等，需要學(xué)術(shù)性護理不斷調(diào)整教學(xué)內(nèi)容和方向。護理教育需要納入的新課程有老年學(xué)、慢性疾病管理、家庭和社區(qū)護理、人與環(huán)境的相互作用、流行病學(xué)、遺傳學(xué)和基因組學(xué)，以及醫(yī)學(xué)倫理學(xué)。（2）學(xué)術(shù)性護理的責任和認證標準。美國國家保健目標強調(diào)學(xué)術(shù)性護理，應(yīng)注重將知識整合到團隊合作、部門協(xié)作、健康教育、家庭或社區(qū)的初級保健及門診護理；護理課程中的替代療法；傳統(tǒng)的護理課程；設(shè)計跨專業(yè)教育課程，注重臨床勝任力的培養(yǎng)；整合仿真和高科技，創(chuàng)造無隙的教育途徑，以概念為基礎(chǔ)的學(xué)習(xí)方法等，鼓勵學(xué)生自主學(xué)習(xí)，增加彈性學(xué)習(xí)的內(nèi)容，通過服務(wù)在實踐中學(xué)習(xí)社區(qū)護理的需求。美國大學(xué)護理教育委員會評估護理教育質(zhì)量的4個標準包括：任務(wù)和管理；制度承諾與資源保障；課程質(zhì)量（課程和教學(xué)實踐）；計劃效果（學(xué)生成果，教師成果和項目成果）。（3）不同層次的護理教育課程的要點。包括護理課程預(yù)期的效果、護理學(xué)士學(xué)位課程改革、學(xué)術(shù)實踐合作、學(xué)生實踐的引導(dǎo)知識、學(xué)士學(xué)位核心課程、碩士學(xué)位課程要點、博士學(xué)位課程要點等。

護理教育；轉(zhuǎn)型；認證標準；課程

G42

A

10.16460/j.issn1008-9969.2017.08.075

2016-11-18

ZHAN Lin,female,PhD,RN,FAAN,Dean and Professor.