Guest Editorial

Exploring nursing education in The People's Republic of China, Japan and Turkey

Marshelle Thobaben
Department of Nursing, Humboldt State University, Arcata CA, United States of America

Deborah A Roberts
Department of Nursing, Humboldt State University, Arcata CA, United States of America

Aysel Badir
School of Health Sciences, Koc University, Nisantasi -Istanbul, Turkey

Hongwei Wan
Department of Nursing, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China

Hiroshi Murayama
Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan

Sachiyo Murashima
Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan

Astako Taguchi
Department of Community Health Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan

PP: 005 - 016

Abstract

The global nursing shortage has caused competition and cooperation between countries desperate for registered nurses (RNs), and has lead to an increase in migration and international recruitment of nurses. Some nursing diplomas or degrees earned in one country may not be transferable to another. As a result, there is growing interest in common standards and competencies of entry-level nurses to guide future registered nurse agreements between countries or multi-country licensure programs.

An exploratory study was conducted to investigate how entry-level nurses are educated throughout the world. The researchers sent a nursing education questionnaire to nurse educators in eleven countries inviting them to participate in the study. Nurse educators from The People's Republic of China, Japan and Turkey were the first to agree to participate in the study. They responded to questions about their country's nursing history, types of nursing programs, use of national nursing licensing examination, and social and political influences on nursing education. The nurse researchers did an analysis and comparison of the nursing education in each country.

Keywords

The People's Republic of China; nursing education; Japanese nursing education; Turkish nursing education; nursing history; international nursing education; global nursing shortage

Article Text

Purpose of the Study

The purpose of this exploratory study was to examine the history of modern nursing education in China, Japan and Turkey, the types of entry level nursing education, advanced degrees and the current challenges concerning the future of nursing education in each country. In addition, this study was conducted to obtain information about each country's historical, social and political influences on nursing education.

The Problem

The global nursing shortage has caused competition and cooperation between countries desperate for registered nurses (RNs). This has lead to an increasing trend toward migration and international recruitment of nurses. Some nursing diplomas or degrees earned in one country may not be transferable to another. This causes the inability of the nurse to practice without further education and a delay in fulfilling the role as a registered nurse. As a result, there is growing interest in common standards and competencies of entry-level nurses to guide future registered nurse agreements between countries or multi-country licensure programs.

Methodology

The researchers emailed a letter of invitation to participate in the nursing education study to nurse educators from Australia, Brazil, Canada, The People's Republic of China, Finland, Japan, Mexico, New Zealand, Taiwan, Turkey and United States. The researchers either knew the nurse educators in each country or had identified key nursing educators through an extensive literature review. Nurse educators from The People's Republic of China, Japan and Turkey agreed to participate in the study. They responded in writing to an open-ended questionnaire about nursing education in their respective country. They were invited to edit and co-author this article.

The nursing education questionnaire was designed for nurse educators to self-report information about their respective country's nursing programs. It was developed by searching for information regarding the historical perspectives of nursing education and international nursing programs. The questions were developed to elicit information about history of modern nursing education, the types of nursing education programs, and the social and political influences on nursing education. The questions were grouped together on the same topic to make the questionnaire easier to answer.

The researchers believed the answers to these questions would contribute to the information about how nurses are educated throughout the world. Refer to Table 1: Questionnaire on Nursing Education, to review the questionnaire that was used in this study. The researchers compiled and analyzed the nurse educators' responses to the questionnaire, as well as, data they had complied from a literature review on international nursing education. They sent their findings to the respective nurse educators in each country to review and validate its accuracy.

Findings

History of modern nursing education

The People's Republic of China

In 1842, Christian missionaries from the United States (U.S.) introduced modern nursing education based on western sciences to China. In 1888, Esther H. Butler and Ella Johnson, both U.S. educated nurses, started the first hospital- based nursing schools (Chen, 1996; Xu et al., 2000). In 1910, Nina Gage, as part of Yale mission in Changsha, established a nursing training program. Ms. Gage became the president of the Nurses' Association of China and Dean of the Hunan-Yale School of Nursing (Chen, 1996; Xu et al., 2000).

By 1915, nursing examinations were given to certify that nurses were competent to practice (Chan,Wong, 1999).

In 1920, Anna Wolf, another U.S. nurse, was instrumental in the establishment of first collegiate nursing program at Peking Union Medical College (PUMC). It was also the first baccalaureate level nursing program in Asia (Hong, Yatsushiro, 2003).This represented a change in the nursing curriculum with an emphasis in theory rather than service. Unfortunately, after the establishment of New China in 1949, all baccalaureate nursing programs were degraded to a secondary level of nursing education (Hong, Yatsushiro, 2003). For 30 years, there were no baccalaureate nursing programs in China.

In 1930, the Chinese government funded the first secondary-level (technical) nursing school. These programs were hospital-based, three to four years in length and taught primarily by unqualified faculty (Xu et al., 2000).

During the Cultural Revolution, from 1966 to 1976, nursing education was deemed nonessential and nearly all nursing schools were closed (Chan, Wong, 1999).

University diploma nursing education was started in the 1980s. In 1983, Tianjin Medical College began the first college level nursing program the government had allowed since the Cultural Revolution (Chan, Wong, 1999).

In the early 1990s Beijing Nursing School, Beijing Medical University admitted its first Masters Degree students. The first nursing doctoral- level (PhD) program is a collaborative education effort between Johns Hopkins University in Baltimore Maryland, and Peking Union Medical College, The Second Military Medical University, in Shanghai. It enrolled its first students in 2004.

Japan

In 1884, modern nursing was introduced when a physician influenced by Florence Nightingale started the first training program for nurses (Primono, 2000). In 1915, the first national laws regulating nursing practice were established. They required that each nursing program be a minimum of two years in length, and eligible students be female and at least 18 years old. They also required each region to develop and administer its own nursing licensing examination (Anders, 1994).

The demands of World War II changed the 1915 laws by lowering the entry age to nursing schools to 16 due to the severe nursing shortage in 1934. In 1947, males were permitted to enter the nursing profession. In 1948, 18 again became the entry age for students admitted to nursing schools.

Due to the nursing shortage, in 1952, a law was passed to have an assistant nurse, similar to licensed vocational nurses in the US. The two-year nursing training programs admitted students following their graduation from middle school. The law was amended in 1956 to allow the assistant nurse to become a R.N. after completing a two nursing program and passing the national examination for licensure as a RNs (Anders, 1994).

In 1967, a revision of the regulations governing the registered nurse curriculum among other things, de-emphasized nursing skills and emphasized the application of theoretical knowledge, critical thinking skills and understanding the effects of culture on nursing care.

In 1952, the first Bachelor of Science nursing program was established at Kochi Women's College and the second began in 1953 at the University of Tokyo. The years from 1967-1989 brought many new technological changes to Japan, which prompted the Division of Nursing within the Ministry of Health and Welfare to revise regulations defining nursing curriculum changes oriented towards a four year program.

In 1979, The School of Nursing, Chiba University, started the first Masters of Science degree in nursing. In 1988, St. Luke's College of Nursing in Tokyo, admitted it first doctoral students.

In 1992, with the establishment of the Nursing Human Resource Law, universities were encouraged to develop the curriculum for a bachelor's degree in nursing.

In 1996, the Certified Nurse Specialist System was established. Nurse specialists are educated at the Master's level and specialize in oncology, chronic, critical care mental health, family care, community health, pediatric, maternal or geriatrics nursing. The number of nurses completing both master's and doctoral programs has increased in recent years.

Turkey

Florence Nightingale had an important influence on the modern nursing in Turkey. This occurred mainly during the Crimean War, when nurses were caring for wounded Turkish and English soldiers in Selimiye Barracks in Istanbul.

A six month course in 1912 saw the beginning of the nursing profession with its first organized nursing program (Senturk 1985; Uyer 1984). In 1920, U.S. established The Admiral Bristol School of Nursing in Istanbul. This evolved into KOC University School of Health Sciences in 1999. The Red Crescent Organization (Kızılayı) established the first Turkish Nursing School of the Republic Period in 1925, and the Ministry of Defense opened the first Military School of Nursing in 1939. In 1946, the Ministry of Health and Social Assistance established two nursing schools in Istanbul (Senturk, 1985).

In 1958, the diploma programs were extended from three to four years and their name was changed to 'Health Colleges' and in 1976 to 'Health Vocational Lyceums'. In 1985, Associate Degree Nursing Programs, two-year programs, were established and terminated in 1996. In 1991, nurses graduating from Health Vocational Lyceums were given an opportunity to register with the Distance Learning Faculty to obtain an Associate Degree. Nurses who have associate degrees have a right to register for basic Baccalaureate Degree nursing programs by passing the 'vertical transfer exam', which is administered by the Turkish Higher Education Council.

Health Vocational Lyceums were closed to standardize nursing education in 1996 due to persistent efforts of nursing leaders. The Ministry of Health and Turkish Higher Education Council signed a contract to convert all health vocational lyceums to Schools of Health Sciences. However, in 2001, the Ministry of Health reinstated admissions to vocational programs and renamed them 'Health Professional High Schools'. These schools offer training for a range of health professionals such as health technician, midwife, and laboratory technician (Ülker et al 2001; Ülker, 2003).

In 1955, the first Baccalaureate of Science nursing program was established at Ege University in Izmir. In 1950s twelve nurses received scholarships to complete nursing BSN and MSN degrees at Colombia University in the US.; subsequently, they founded nursing programs in Turkey based on US. nursing models (Sentürk, 1985; Uyer 1984; Robertson et al., 1992). In 1986 (Yavuz, 2004), Turkey was one of only five European countries providing a basic university level nursing education (the other countries were England, Belgium, Iceland and Greece).

The Master of Science degree nursing programs were begun in 1968 and the doctoral degree nursing programs were implemented in 1972 (Sentürk, 1985; Uyer, 1984).

Types of nursing programs

Refer to Table 2: Types of Undergraduate Nursing Programs in The People's Republic of China, Japan and Turkey, for a list of the types of nursing programs in The People's Republic of China, Japan and Turkey.

The People's Republic of China

The three levels of nursing programs in The People's Republic of China are health schools (first level, secondary vocational education), university diploma (second level) and university degree (third level) programs. Graduates of all programs are eligible to be registered nurses.

Health school-based nursing programs are the backbone of the Chinese health care system. One type of health school program admits students who have graduated from high school; they have a 2-3 year course of study. The other type admits students from middle/junior high, typically students who are 14-15 year of age. After completing the 3-4 year curriculum, the students are only 17-18 years old. There is concern that these nurses may be too young and not mature or independent enough to make critical patient care decisions (Chan, Wong, 1999). After graduation from health schools, students sit for the State Nurses Registration Examination (RN). Ninety-nine percent (99%) of the 1.2 million nurses in The People's Republic of China have obtained their education from these programs (Xu et al., 2000; Xu et al., 2002).

University diploma programs are three-year curriculums for high school graduates. These graduates can practice in clinical nursing and teach (Chan, Wong, 1999).

The Bachelor of Science Degree Nursing Programs (BSN) are administered by the Division of Higher Medical Education, Department of Medical Science in the Ministry of Health and Ministry of Education. Each university is responsible for its own curriculum and nursing course hours, and each medical university has its own affiliated hospitals for students to practice.

Most BSN programs have a 5-year curriculum and admit high school graduates through a highly a competitive National University Admission Examination (Chan, Wong, 1999).The curriculum is primarily physiologically based and disease-orientated similar to that of a medical education curriculum. Students are required to complete the basic and foundation courses in two and a half years and the nursing courses in one and a half years. They spend a year in hospitals completing an internship in basic nursing, internal medicine, surgical, pediatric, and maternity nursing. These graduates work in nursing education and nursing management positions.

The School of Nursing, Peking Union Medical College, has recently changed its curriculum from a medical to a nursing model curriculum with the support of The Ministry of Health. The development of the curriculum was influenced by the western world. For example, they use nursing diagnoses categories (Nutrition- Elimination, Activity-Rest, etc.) and have courses on health care delivery systems, community health nursing and professional development (Hong, Yatsushiro, 2003).

In 1994, the National Nursing Licensure Examination (NNLE), a standardized national registration examination, was established to govern the entry into nursing. Degree level graduates are exempt from the examination and granted automatic certification (Xu, et al, 2000). The initial period of certification is 2 years.

Traditional Chinese medicine (TCM) is integrated into the nursing curriculum and nursing practice. In the past few years, psychology and primary prevention has been added to nursing curriculums (Chan, Wong, 1999; Xu et al., 2000).

There are two specialized secondary nursing programs that are unique. One is the traditional Chinese medicine nursing school (zhongyi huli yuexiao), whose goal is to prepare nurses versed in applying a holistic view of Traditional Chinese Medicine (TCM) into their practice. The nurses use TCM treatment modalities, such as acupuncture and dietary therapy (Xu et al., 2000).The other specialized secondary nursing program is the foreign language nursing program, which educates nurses in a specific foreign language to be able to work in joint ventures and overseas. English and Japanese foreign language nursing programs are the most popular (Xu et al., 2000).

In 1996, the Ministry of Public Health introduced a mandate for continuing education, requiring all nurses to provide evidence of continuing education credits for renewal of registration (Wong et al., 2000; Xu et al., 2000).

Due to the lack of nursing educators, in many nursing schools, hospital staff and medical doctors also teach nursing students, particularly the professional foundation courses (Xu et al., 2000). The students use nursing textbooks to supplement classroom teaching. Even though males may become nurses, the number of male nurses is minimal when compared to female.

Japan

The Japanese nursing education system has three different types of programs that allow students to become eligible for a national certificate as a registered nurse. These are the junior college nursing programs that have two or three year curriculum, hospital affiliated or diploma programs, which have three year curriculum, and college or university programs, which have four year curriculum (Primomo, 2000). To enrol in any of the programs, the student must be a high school graduate.

The nursing diploma programs are the most common. The Division of Nursing of the Ministry of Health, Labor and Welfare oversees these programs. The Japanese Nursing Association regulates clinical specialist programs.

Admission to a university nursing program is based on a written entrance examination administered by each school and high school. The Ministry of Education, culture, Sports, Science and Technology regulates baccalaureate and higher degree programs, and licenses the schools. Since the curriculum revolution of 1996, all schools may determine their own educational curriculum. This gives schools the flexibility to transfer credits from one school to another allowing students to transfer smoothly.

The nursing curriculum includes nursing courses in fundamentals, adult health, geriatrics, mental health, pediatrics and obstetrics as well as home health nursing care, which was introduced into the curriculum in 1997. The current curriculum relies on lecture with memorization of facts. The beginning courses offer very little clinical experience, but in the latter years of a program of practice, students may be in clinical up to 45 hours each week. Clinical practice includes both the hospital and visiting nurse services. The faculty ratio varies between types of programs. For example, the 3 year program have a faculty ratio of 1 to 15, a 2 year program 1 to 11 while a baccalaureate program may have a ratio of between 1 to 17 or 1 to 33 depending on student assignments.

Due to the shortage of nursing faculty, physicians are the primary faculty in the 3 year programs. Textbooks are readily available to all students and faculty for nursing courses as well as the science courses such as anatomy and physiology. Students may buy them individually or the school of nursing purchases the books for the students to share.

There are three nursing licenses: registered nurse, public health nurse, and nurse midwife. Public Health and Nurse Midwifery nurses complete an additional six months-one year of education after their basic program and are required to pass an additional national board examination. The Minister of Health, Labor and Welfare regulates curriculum for nursing, public health nursing, midwifery and registered clinical nurse specialist programs.

The numbers of baccalaureate, master's and doctoral programs have been increasing rapidly in Japan. In 1975, 3 baccalaureate, 2 masters and 2 doctoral programs existed. By May 2004, these programs increased to 118, 72 and 25 respectively.

While females continue to dominate the nursing profession in Japan, males are permitted to enter parts of the profession as registered nurses since 1947 and as public health nurses since 1994. In 2002, males that were employed represented 26,000 of the 740,000 registered nurses and public health nurses. Presently, only females are permitted to enter midwifery programs.

Turkey

The Turkish nursing education system has two basic types of programs, which are Health Professional High Schools leading to a diploma in nursing, and university based nursing programs leading to a Bachelor of Science in nursing degree.

Health Professional High Schools accept students only after a minimum of eight years of secondary school and complete the health professional curriculum in an additional four years. They do not have nursing programs but have other health professionals such as radiology technician, midwifery, and emergency medical technician. There are 285 Health Professional High Schools working under the Ministry of Health in Turkey.

The Schools of Nursing and School of Health Sciences in Turkey offer the Bachelor of Science Nursing Degree. Students are admitted to the university through a highly competitive General University Entrance Examination, which is organized by Turkish Higher Education Council. The programs are four years in length. There are nine schools of nursing at public universities offering a baccalaureate, masters, or doctorate degree in Nursing.

The Baccalaureate Science Degree programs in Nursing include nine basic nursing courses with both theory and clinical practice. The courses include nursing techniques and methods, medical-surgical, obstetric and maternity, pediatric, community, and mental health nursing, and nursing management. Two theoretical course hours are equal to two credits. Clinical course credits vary from two to four clinical hours for each credit. Included in the curriculum are elective courses such as art history and sociology, anthropology, and physiology. The History of Turkish Revolution and Turkish language are mandatory courses in all Turkish Universities.

Undergraduate (Baccalaureate Degree) and graduate levels of education (Yavuz, 2004) are controlled by the Turkish Council of Higher Education (Yuksek Ogretim Kurumu) in Turkey. There are currently eight master and doctorate programs (Fundamentals of Nursing, Medical Nursing, Surgical Nursing, Women's Health and Obstetrics, Children's Health and Diseases, Mental Health, Community Health, and Education in Nursing).

Students do not have nursing textbooks available for their personal use, but nursing faculty are trying to publish nursing books for nursing students and nurses. Adjunct medical and pharmacology faculty usually teach the core health sciences courses such as anatomy, physiology, microbiology and pharmacology.

Graduates from nursing programs are not required to take a registration exam in Turkey. All certificates/diplomas have to be approved by Turkish Republic Ministry of Health. European Union standards dictate the need for a 'registration exam' and this reform is being considered in Turkey for all professionals.

There are approximately 72 Schools of Health Sciences that offer license degree education in nursing, midwifery and health technician programs. They were established in 1996 by the contract between Ministry of Health and Turkish Higher Education Council. There are 66 'nursing programs', thirty 'midwifery programs' and fifteen 'health technician' programs in these schools. There are 45,560 health technicians that work as nurses in Turkey. These health technicians are educated with the same curriculum as nurses and work in a nurse role in hospitals and other health care settings but not counted as nurses.

Approximately one-third of the faculty teaching in the Health Sciences programs has only a Bachelor of Science Nursing degree. The student- faculty ratio varies between sixty-to-one and fifteen-to-one (Ülker et al., 2001).The students do not have adequate clinical experience due to a lack of clinical practice sites, educational equipment, and infrastructure. Directors of the most of these programs are not nurses despite the European Union recommendations that nursing schools have to be administered by nursing professionals.

The Nursing Act states that one has to be a woman in order to be a nurse. There have been attempts for decades to change this law by the Turkish Nursing Authorities but the proposal bill has yet to become law. Cultural prejudices against the idea of male nurses have maintained this system of male nursing technicians. Legal reform is needed to change the status of these male health professionals.

Challenges concerning the future of nursing education

The People's Republic of China

During the last decade, nursing education has developed rapidly in alignment with the economic enhancement of the country. Due to the 30-year abolition of nursing from academia, there is not a sufficient pool of nursing faculty with adequate qualifications to teach (Xu et al., 2000). Because the country lacks the doctoral-level nurse education programs, nurses who seek a career in higher education, research and administration must go abroad for their education. The often do not return to The People's Republic of China (Xu et al., 2000).

Nursing education is shifting its focus from an illness to a health model, with increasing emphasis on primary health care expanding its clinical settings to include communities, families, homes for the elderly, and health clinics. Nursing curriculum needs to include a broader knowledge base covering behavioral and biological sciences, and a move towards student-centered approaches to teaching, and preparing to care for an increasing elderly population (Chan, Wong, 1999; Wong et al., 2000).

An important cultural consideration as nursing curriculums are adopting practices from the Western world is importance of keeping Traditional Chinese Medicine (TCM) as a part of the nursing curriculum (Wong et al., 2000).TCM has been practiced in The People's Republic of China for 4000 years and is an important part of health care.

Outside the profession, nursing is still perceived in both economic and social terms as a less desirable career. It still remains an exclusive field for females owing to the predominant social stigma and prejudice (Xu et al., 2000).

Japan

An aspiration for nursing in Japan is to have all entry-level nurses educated at a baccalaureate level. To attain the goal there is a need for more baccalaureate programs. Even though there has been increase in the number of qualified faculty, there remains a need for more nurse educators with masters and doctorates.

Many nurse educators are interested in having nursing education be a nursing rather than a medical model. To accomplish this goal, the nursing faculty shortage will need to be solved and nursing curriculums will need to change to reflect a nursing model rather than a medical model.

Turkey

Turkey is a candidate country for membership in the European Union (EU), which is the world's largest trading block. Potential membership in EU has been the driving force behind Turkey making major political and social reforms including those that have to do with regulations on nursing education. In 2002, the National Nursing Core Curriculum, with the five directors of Schools of Nursing as the members, was established to prepare a National Nursing Core Educational Program to present to the Turkish Higher Education Council (National Nursing Education Core Educational Program, 2003). The purpose of the program is to standardize nursing curriculum on a national level according to the standards enshrined in the European Union criteria including a holistic approach to patient care with the protection of human rights, professional ethics, teamwork, critical thinking and a dedication to the profession through the ability to make changes and lifelong learning. This standardization and reform on a national level originally was organized and attended by nursing educators only. Recently clinical nurses have also shown support through their attendance and participation.

Other challenges influencing the future of nursing are that The Society of Turkish Nurses, the official organization for nursing, is not responsible for establishing or monitoring standards of nursing education and practice in Turkey. The Nursing Law of 1954, which defines the scope of nursing practice, is not in accordance with current nursing practice and health care demands of society. Between 1988 and 1993, Ministry of Health implemented a National Health Policy and program of health care reform, which carried out a major study to identify current needs and set objectives for future action. In 1997, a new nursing draft law was developed but never enacted due to a change of government (Savas et al., 2002). Nursing leaders have continued to be unsuccessful in implementing a new Nursing Act.

Additionally, the organizational structures in hospitals do not have uniformity and nursing services as a whole lacks organizational structure. Finally, nursing continuing education and in-service education programs need to be more rigorous and increased in number to enhance the learning of nursing graduates.

Discussion

Comparisons in nursing education

The People's Republic of China, Japan and Turkey has many similarities and some significant differences in nursing education. They all have had a long history and evolution of the nursing profession. All have had an influence of western sciences on nursing education and practice. Each country has experienced nursing and nurse faculty shortages primarily due to the increase and availability of higher education for nurses. All three countries have been striving for an increase in the number of baccalaureate, master's and doctorate prepared faculty and nurses. The basic types of nursing programs vary slightly among the countries. They each have some form of associate degree nursing programs or hospital based or diploma programs and baccalaureate programs. The length of these programs varies from two to five years.

Some form of ranked admission criteria to nursing programs exists in all three countries. Either by examination or previous educational accomplishments, students are carefully selected for the nursing profession. The nursing curriculum contains a combination of basic science courses as well as nursing courses of fundamentals, adult health, mental health, pediatrics and obstetrics. Nursing remains a predominantly female profession in all three countries.

Some significant differences in resources available to nursing programs exist. Some of the Turkish nursing programs have a high student faculty ratio, which can be as high as sixty students to one faculty. Additionally, students have no textbooks available for personal use due to the unavailability of nursing textbooks in the Turkish language. Japan has low student faculty ratio and textbooks are available for students and faculty.

Nursing graduates from The People's Republic of China and Japan are required to pass a national examination to be a registered nurse. China exempts degree level graduates from the examination. Turkey does not have a national examination requirement to be a registered nurse.

A major concern for each of these countries is the delivery of the curriculum by qualified nursing educators and creating a new generation of nursing educators. There have and continue to be governmental and political factors that are influencing the direction of nursing education and practice in all three countries.

Limitations of the Study

The limitations of this study included the small sample size of the three countries that initially responded to the questionnaire. The study lacked an in-depth analysis of the content of the nursing courses, the type of nursing skills learned or the type of health care facilities used. The study did not include an analysis of the nurse practice acts or the scope of nursing practice to compare the level of nursing practice at the patient bedside. Additionally, the researchers were not fluent in Chinese, Japanese or Turkish languages, which may have lead to misinterpretations or misunderstanding of information sent by the nurse educators, and hindered their ability to read articles in those native languages. Also included in the limitations was the amount and depth of information shared by each contributing nurse educator, particularly, regarding the political and social issues currently influencing nursing education. Conversely, the nurse educators' primary languages were not English, which also may have caused misinterpretations or misunderstanding of information sent by the nurse researchers.

Conclusions

The global nursing shortage has lead to an increase in migration and international recruitment of nurses. This has created a growing interest in common standards, and competencies of entry-level nurses. An exploratory study was conducted to investigate how entry-level nurses are educated worldwide. This peer-reviewed Guest Editorial has provided information on nursing education in The People's Republic of China, Japan and Turkey. The research into the types of nursing education fits into a larger picture in each country of nurses' political struggle throughout the centuries to establish nursing and nursing education standards.

A more in-depth study is needed to determine if the nursing graduates of these programs have comparable nursing theory and clinical nursing expertise. There are significant differences in education in these three countries alone. This study is part of a larger research project investigating nursing programs throughout the world. A comparison of nursing programs in Canada, Finland and the United States will appear in future issues of this journal.

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