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Nursing Education


To place nursing education into perspective, it is helpful to reflect on the health care environment and the role of the nurse in that environment. The health care landscape in the United States has been changing at an unprecedented rate. Nursing education also has undergone changes to keep pace and to prepare leaders who are highly educated and technically sharp decision-makers and clinicians. What is most noteworthy, however, is not that change has occurred but rather that the rate of change since 1980 has been greater than during similar periods. Factors driving the transformations include new medical and technological advances, new health care delivery systems, and expanded roles for nurses.

Nurses are the largest single group of health care professionals but they do not practice in isolation. Rather they are an integral part of health care teams, institutions, and systems. As health care continues to move outside the hospital, the demand for nurses who can function across systems and direct a continuum of care is rising. The changing health care environment has not only changed the role of the nurse, it has also affected the supplydemand ratio. Hospitalized patients have multiple health problems, are more acutely ill, and are discharged sooner. This has increased the demand for nurses in acute care institutions at the same time that more nurses are needed in home and community settings. Given trends that emphasize health promotion and disease prevention, the need for acute and chronic care is skyrocketing.

The Federal Division of Nursing predicts that by 2010, the growing demand for nurses with bachelor of science in nursing (B.S.N.) and master of science in nursing (M.S.N.) degrees will outstrip the supply and that by 2020, the demand for B.S.N. and M.S.N. graduates will grow nearly twice as fast as the expected increase in the workforce. The predicted need for nurses is sobering, yet it is important to acknowledge that the impending crisis is not solely numbers based. The question is not only how many nurses will be available, but more importantly, will their educational preparation be appropriate to meet future health care needs. Based on the Federal Nursing Division's data, the answer is to increase the number of bachelor's, master's, and doctorate-level nurses.

Bachelor of Science in Nursing Degree

In 1996 the American Association of Colleges of Nursing affirmed nursing's place in American higher education by stating that the minimum educational requirement for professional nursing is the bachelor of science in nursing (B.S.N.) degree. B.S.N. programs are offered by four-year colleges and universities. Most generic B.S.N. programs are four academic years, although some students who have other responsibilities may choose to extend their programs. The term generic refers to a program designed for students studying nursing for the first time. By comparison, some B.S.N. programs have degree completion tracks for registered nurses (RNs) and licensed practical nurses (LPNs) who have completed basic nursing programs in hospitals or community colleges. Some programs also offer tracks for individuals with bachelor's degrees in other majors. B.S.N. programs must be approved by the state board of nursing.

A B.S.N. degree enables graduates to not only launch a successful career in nursing, but also to appreciate a more meaningful life. Therefore, the curriculum includes courses in nursing as well as the arts and sciences. Because the B.S.N. graduate is prepared as a generalist, nursing courses include both theory and clinical experiences and in most specialty areas, such as adult, community, maternal-child, pediatric, psychiatric, and critical care nursing. In some B.S.N. programs, students enroll in nursing courses at the freshman or sophomore level with courses in the major along with arts and sciences integrated throughout the program. In other programs, nursing courses are concentrated at the junior and senior levels. The number of credit hours required for a B.S.N. degree usually ranges from 120 to 130. Upon completing the degree, graduates are eligible to take the National Council Licensing Examination (NCLEX) to become licensed as a registered nurse. By law, nurses must be licensed to practice in the state where they work.

A strong background in science, mathematics, and verbal skills is needed to succeed in nursing. The admission process varies among institutions but typical criteria include: official transcripts with a minimum grade point average (GPA) of 2.0; SAT or ACT Assessment score, and TOEFL (Test of English as a Foreign Language) for foreign students; essay; and letters of recommendation. Some B.S.N. programs admit students directly into the major. Others admit students initially to the institution and require students to apply for admission to the major after completing prerequisite courses including the sciences.

Master of Science in Nursing Degree

Whereas bachelor's degree graduates are generalists, master's degree graduates are specialists. The master of science in nursing (M.S.N.) degree program prepares graduates to be advanced practice nurses (APNs) with in-depth theory and practice in a clinical specialty. Some M.S.N. programs combine both clinical and functional roles (e.g. education, administration, case management). However, the American Association of Colleges of Nursing (1996) concluded that the clinical role should be the primary focus for all master's programs.

Most master's students select one of four tracks or primary roles: clinical nurse specialist (CNS), nurse practitioner (NP), certified registered nurse anesthetist (CRNA), or certified nurse midwife (CNM). The CNS is an APN with expertise in theory and research-based clinical nursing practice. In addition to clinical practice, major roles of the CNS include teaching, research, consulting, and management, all within an area of specialization, such as acute care, adult health, community health, critical care, gerontology, maternal-child, mental health, neonatology, oncology, pediatrics, or women's health. The NP is an APN who is a primary care provider to individuals and families in multiple settings. Originally developed to function as a physician extender, the NP role has evolved to incorporate a more holistic nursing approach to illness prevention and health promotion. NPs assess, diagnose, treat, prescribe, monitor, and refer patients as appropriate. The CRNA works closely with a physician and administers anesthesia in hospitals and outpatient settings. The CNM manages routine obstetrical cases. APNs have a collaborative agreement with a physician.

Although M.S.N. programs offer a wide choice of clinical specialties, most curricula include core courses such as statistics, research, professional role, concepts and theories, health policy, ethics, and economics. Other required courses include advanced study in physiology and pathology, pharmacology, and health assessment. The number of clinical hours is program specific but ranges between 500 and 750 are common. M.S.N. programs may require a thesis or other culminating project, and a comprehensive examination. The number of credit hours required for the M.S.N. degree typically ranges from 36 to 48. Although the master of science in nursing (M.S.N.) is the degree awarded most frequently, some institutions award a master of nursing (M.N.), a master of science (M.S.), or a master of arts (M.A.) degree. The difference is more a function of institutional organization, not the graduate nursing curriculum.

The admission process is institution specific but typical admission criteria include the following: official transcript verifying a B.S.N. degree from an accredited program with a minimum GPA of 3.0; undergraduate courses or demonstrated competency in health assessment, statistics, and informatics; practice in nursing; Graduate Record Exam (GRE), Miller Analogy Test (MAT), or TOEFL for foreign students; letters of recommendation; résumé; and an essay. The above discussion assumes that a M.S.N. applicant has a B.S.N. degree, but it is possible for nurses with no bachelor's degree or a non-nursing bachelor's degree, and for individuals with no background in nursing to be admitted into some graduate nursing degree programs.

After completing a master's degree or postmaster's certificate, CNSs and NPs may take national certifying examinations such as those offered by the American Nurses Credentialing Center (ANCC) providing their programs included the requisite content and hours in a clinical specialty. This credentialing system further demonstrates nursing's everincreasing standards and commitment to excellence.

Doctoral Degrees in Nursing

The quality of nursing education has increased further as evidenced by the fact that doctoral degree programs in nursing, and even postdoctoral programs, have become an integral part of American higher education. Prior to 1960 there were no doctoral programs in nursing. During the 1960s nursing was added as a minor to other Ph.D. degree programs. It was not until 1970 that Ph.D. programs in nursing emerged, but the number of programs has increased significantly. At the beginning of the twenty-first century, there are more than seventy-five doctoral programs in nursing leading to a Doctor of Philosophy (Ph.D.) or a Doctor of Science in Nursing (D.N.S., D.S.N., or D.N.Sc.) degree.

Both the Ph.D. and D.N.S. degree programs focus on research and "prepare students to pursue intellectual inquiry and conduct independent research for the purpose of extending knowledge" (American Association of Colleges of Nursing, 2001b, p. 2). Stated differently, doctoral programs in nursing enhance the scientific foundation for nursing theory and practice. A research-focused doctoral degree prepares graduates for a variety of positions within higher education, health care, government, and the private sector, such as educator, researcher, administrator, and advanced practice. Career options for nurses prepared at the doctoral level are virtually limitless.

Directed toward preparing graduates for a wide range of scholarly pursuits, most doctoral programs require courses in history, philosophy, and theory of nursing; informatics; research; and in related issues from health care ethics to economics. However, curricula do vary depending upon philosophy, faculty expertise, and other resources. Other requirements include a dissertation, oral defense, and comprehensive examination. The number of credit hours required for the doctoral degree is institution specific.

Criteria for admission to a doctoral program are similar to those for a master's program. Typical criteria include an official transcript verifying a M.S.N. degree with a minimum GPA of 3.0; a strong foundation in statistics; GRE score; practice in nursing; curriculum vitae; letters of recommendation; essay; and interview by a faculty committee.

Higher education is a lifelong investment. Undergraduate and graduate students should investigate several programs to determine which one correlates best with their academic and clinical interests and career goals. Students also should carefully assess multiple institution and program characteristics, especially accreditation status. Colleges and universities are accredited by nationally recognized, regional accrediting associations. Undergraduate and graduate nursing programs may apply for specialty accreditation by the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC). Although accreditation is voluntary, it demonstrates an institution's and program's commitment to continuous improvement and quality education.

See also: Medical Education.


American Association of Colleges of Nursing. 1993. Position Statement on Nursing Education's Agenda for the Twenty-First Century. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1996. The Essentials of Master's Education for Advanced Practice Nursing. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1996. Position Statement on the Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1997. Position Statement on Vision of Baccalaureate and Graduate Nursing Education: The Next Decade. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 1998. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 2001a. Envisioning Doctoral Education for the Future. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing. 2001b. Position Statement on Indicators of Quality in Research-Focused Doctoral Programs in Nursing. Washington, DC: American Association of Colleges of Nursing.

Anderson, Norma E. 1981. "The Historical Development of American Nursing Education." Journal of Nursing Education 20:1836.

Bednash, Geraldine, ed. 2001. Ask a NurseFrom Home Remedies to Hospital Care. New York: Simon and Schuster Source.

Chaska, Norma L., ed. 2001. The Nursing Profession Tomorrow and Beyond. Thousand Oaks: Sage.

Hamric, Ann B.;Spross, Judith A.; and Hanson, Charlene M., eds. 2000. Advanced Nursing Practice. Philadelphia: Saunders.

Carole F. Cashion

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Nursing Education

Nursing Education

Nurses spend more time with patients who are facing the end of life (EOL) than any other member of the health care team. In hospice, nurses have been recognized as the cornerstone of palliative care, and it is increasingly apparent that nurses play an equally important role in palliative care across all settings. Studies have documented that nurses and other members of the health care team are inadequately prepared to care for patients with pain at the EOL. Inadequate care of the dying continues to be a problem in the twenty-first century. Many reasons have been cited for this failure, including inadequacies in the basic and continuing education of health care providers.

Challenges to EOL Care

Numerous studies during the 1980s and 1990s have documented that nurses lack knowledge about pain control, one key aspect of EOL care. Pain management has been described as a situation in which physicians continue to underprescribe, nurses inadequately assess and undermedicate patients, and patients take only a portion of the analgesics prescribed or underreport their pain. Generally, physicians and nurses have an inaccurate knowledge base about common pharmacologic agents used in pain control and have exaggerated fears about the likelihood of addiction. The fear of addiction continues to be a major obstacle to adequate treatment of pain at the EOL.

However, pain management is only one aspect of EOL care. Other EOL needs include management of other physical and psychological symptoms, communication with patients and families, preparation of the staff and family care at the time of death, and many other aspects of care of the dying. Attention to EOL issues, such as a report by the Institute of Medicine on EOL care and action by the U.S. Supreme Court on the right to die, have prompted a focus beyond pain management to include other dimensions of EOL care.

Improving EOL Care

Two milestones, a key EOL care project supported by the Robert Wood Johnson Foundation conducted between 1997 and 2000 and its resultant recommendations and the 1997 Institute of Medicine report on EOL care, have addressed these deficiencies, resulting in increased awareness of EOL issues and spurring changes to EOL care and nursing education.

The Robert Wood Johnson Foundation Project. The Robert Wood Johnson Foundation funded study was conducted by the City of Hope investigators. The overall purpose of this project was to strengthen nursing education to improve EOL care by accomplishing three goals: (1) to improve the content regarding EOL care included in major textbooks used in nursing education; (2) to insure the adequacy of content in EOL care as tested by the national nursing examination, the NCLEX; and (3) to support the key nursing organizations in their efforts to promote improved nursing education and practice in EOL care.

The primary activity for the first goal, improving the content regarding EOL care in nursing textbooks, was a review of fifty major textbooks used in nursing education. These fifty texts were selected from a list of over 700 textbooks used in schools of nursing, and then were stratified by topic areas. The areas selected and number of books included were AIDS/HIV (1), assessment/ diagnosis (3), communication (2), community/ home health (4), critical care (4), emergency (2), ethics/legal issues (5), fundamentals (3), gerontology (3), medical-surgical (5), oncology (2), patient education (2), pediatrics (3), pharmacology (4), psychiatric (3), and nursing review (4).

A detailed framework for analyzing the content of the textbooks was developed by the City of Hope investigators. This framework was based on a review of current literature and expert opinion about optimum EOL care. Nine critical content areas were selected: palliative care defined; quality of life (physical, psychological, social, and spiritual well being); pain; other symptom assessment/ management; communication with dying patients and their family members; role/needs of caregivers in EOL care; death; issues of policy, ethics, and law; and bereavement.

The fifty texts encompassed a total of 45,683 pages. Each text was reviewed using the framework. The reviewer scanned the complete index, table of contents, and all text pages for possible content. The reviewers were very inclusive and liberal in their approach, and when any EOL content was identified, those pages were copied. The copied pages then were analyzed for content using a "cutand-paste" approach in which the content was placed on the analysis grid within the appropriate framework section. Key findings of the study were:

  • Of the 45,683 pages of text reviewed, 902 pages were related to EOL content, representing only 2 percent of the total content.
  • Of 1,750 chapters included in the texts, 24 were related to EOL, representing 1.4 percent of all chapters.
  • The nine EOL topic areas reviewed were included infrequently in the texts' tables of contents or indexes. At least one chapter was devoted to an EOL-related topic in 30 percent of the texts.
  • The EOL topics with the poorest focus in the texts were quality-of-life issues at EOL and role/needs of family caregivers. The areas of strongest content were pain and policy/ ethics issues.
  • Overall, 74 percent of the content in the framework was found to be absent from the texts, 15 percent was present, and 11 percent was present and commendable.

Recommendations from this analysis were presented to a conference of publishers and the City of Hope investigators continue follow up with the editors of these texts and other books in order to improve EOL content in future editions. Major progress has been made to date and the textbook editors and authors have been very responsive.

The second goal of the project, ensuring the adequacy of content in EOL Care, as tested by the NCLEX exam, was also successfully implemented. City of Hope investigators worked with the staff of the National Council of State Boards of Nursing to increase the emphasis of EOL care within the exam to increase its priority for nursing education, and thus the knowledge of practicing nurses. Goal three, supporting key organizations in their efforts to promote nursing education and practice in EOL care, was also achieved. Many nursing organizations have been mobilized to address the deficiencies in EOL care.

In addition to studying nursing education, City of Hope nurse researchers also surveyed over 2,300 practicing nurses to determine their perspectives on EOL care. Respondents were asked to rate these dilemmas based on their occurrence as "not common," "somewhat common," or "very common." The most frequently occurring dilemmas were use of advance directives and preserving patient choice/self-determination, which 37 percent and 23 percent, respectively, cited as very common. Interestingly, 93 percent of respondents cited requests for assisted suicide and requests for euthanasia as not common dilemmas, and 6 percent cited these requests as somewhat common. More than one-third of all nurses reported seven of the nine dilemmas, excluding those of assisted suicide and euthanasia, as somewhat common or very common. Acknowledging the diversity in responses to these dilemmas is important. For example, although 37 percent of respondents reported use of advance directives as very common dilemmas, 31 percent of the respondents reported this area as not common.

Respondents were also asked to rate how much of a barrier each factor was to providing good EOL care in their settings. The items were rated as "not a barrier," "somewhat of a barrier," or "a severe barrier." Respondents most frequently cited "influence of managed care on end-of-life care" (25%) as a severe barrier followed closely by "lack of continuity of care across settings" (23%). The barriers that were reported as common and the diversity of these barriers illustrate the complexity of effective EOL care. The respondents identified not only system barriers (e.g., continuity of care, influence of managed care) but also cited patients' (70%) and family members' (73%) avoidance of death as somewhat of a barrier. Other prominent barriers were health care providers' lack of knowledge and personal discomfort with death.

Institute of Medicine report. The Institute of Medicine report on improving EOL care concluded with seven recommendations, two of which spoke directly to the need for improved professional knowledge:

  • Physicians, nurses, social workers, and other health care professionals must commit themselves to improving care for dying patients and using existing knowledge effectively to prevent and relieve pain and other symptoms.
  • Educators and other health care professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to provide good care for dying patients.

End-of-Life Nursing Consortium

The studies of the 1990s lead to the End-of-Life Nursing Education Consortium (ELNEC) projecta comprehensive, national education program to improve EOL care by nurses. Primary project goals include developing a core of expert nursing educators and coordinating national nursing education efforts in EOL care. This project points to the future of nursing education in the twenty-first century.

This three-and-a-half-year ELNEC project began in February 2000, and is a partnership of the American Association of Colleges of Nursing (AACN) and the City of Hope Cancer Center (COH). A primary goal of the project is to bring together leading nursing groups and perspectives to form a collaborative approach to improve EOL education and care. The ELNEC curriculum has been developed through the work of highly qualified subject matter experts serving as consultants, with extensive input from the advisory board and reviewers. Courses are designed to prepare educators to be instructional resources for their schools and organizations, and serve as a vital force in the dissemination of this important content.

ELNEC includes a total of eight courses, five of which are offered for baccalaureate and associate degree faculty who can then facilitate integration of EOL nursing care in basic nursing curricula. Two courses are planned for school-based, specialty organization, and independent nursing continuing education providers in order to influence practice of nurses in their target groups. The final course will be for state board of nursing representatives to strengthen their commitment to encourage end-of-life education and practice initiatives in their states. In addition, five regional ELNEC courses will be offered.

See also: Communication with Dying; Death Education; Pain and Pain Management; Symptoms and Symptom Management


American Association of Colleges of Nursing. A Peaceful Death. Report from the Robert Wood Johnson End-of-Life Care Roundtable. Washington, DC: Author, 1997.

American Nurses Association. Position Statement on Active Euthanasia and Assisted Suicide. Washington, DC: Author, 1994.

Ferrell, Betty R. "End-of-Life Care: How Well do We Serve Our Patients?" Nursing 28, no. 9 (1998):5860.

Ferrell, Betty R., Marcia Grant, and Rose Virani. "Strengthening Nursing Education to Improve End-of-Life Care." Nursing Outlook 47, no. 6 (1999):252256.

Ferrell, Betty, Rose Virani, and Marcia Grant. "Analysis of End-of-Life Content in Nursing Textbooks." Oncology Nursing Forum 26, no. 5 (1999):869876.

Ferrell, Betty, Rose Virani, Marcia Grant, Patrick Coyne, and Gwen Uman. "Beyond the Supreme Court Decision: Nursing Perspectives on End-of-Life Care." Oncology Nursing Forum 27, no. 3 (2000): 445455.

Field, Marilyn J., and Chris K. Cassel, eds. Approaching Death: Improving Care at the End of Life. Report of the Institute of Medicine Task Force. Washington, DC: National Academy Press, 1997.

Internet Resources

American Association of Colleges of Nursing. "ELNEC Project." In the American Association of Colleges of Nursing [web site]. Available from


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"Nursing Education." Macmillan Encyclopedia of Death and Dying. . 19 Jan. 2018 <>.

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"Nursing Education." Macmillan Encyclopedia of Death and Dying. . Retrieved January 19, 2018 from