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Globalization of Higher Education in Nursing: Trends and Future Directions in Harmonizing Nursing Education Internationally 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 when calculating equivalencies.