Guest Editorial

Exploring nurse education in Canada, Finland and the United States

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

Susan E French
Professor, School of Nursing, McGill University, Montreal, Quebec, Canada

Marianne Tallberg
Adjunct Professor, Kuopio University, Kuopio, Finland

PP: 119 - 133

Abstract

A global registered nursing (RN) shortage has caused an increase in migration and international recruitment of nurses. There is growing interest among some countries of having common standards and competencies for entry-level registered nurses to guide future registered nurse agreements between countries or multi-country licensure programs. Nursing education in one country may not be accepted as equivalent for a nurse to become licensed in another country.

An exploratory study was conducted to gain a better understanding of how nurses are educated in various countries. Nurse researchers sent a nursing education questionnaire to nurse educators in eleven countries inviting them to participate in the study. Nurse educators from six countries agreed to participate in the study. They provided information about their country's nursing history, types of nursing programs, use of national nursing licensing examination, and political influences on nursing education.

The People's Republic of China, Japan and Turkey nurse educators' responses were the first to be analyzed and the results were published in the July/August 2005 issue of Contemporary Nurse (volume 19/1-2). This second article (in Contemporary Nurse volume 20/2) provides information about and a comparison of nursing programs in Canada, Finland and the United States.

Keywords

Canadian nursing education; Finnish nursing education; United States nursing education; nursing history; international nursing education; global nursing shortage; international recruitment; skills migration

Article Text

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. Nursing degrees or diplomas earned in one country may not be transferable to another country, preventing nurses from working without repeating some or all of their previous nursing education courses. As a result, there is growing interest in developing common standards and competencies of entry-level nurses to guide future registered nurse agreements between countries or multi-country licensure programs.

Methodology

The nurse researchers emailed a letter of invitation to participate in a nursing education exploratory study to nurse educators they knew or had identified through an extensive literature review. Previously, nurse educators from The People's Republic of China, Japan and Turkey agreed to participate in the nursing education study and the results of their responses was published in the July 2005 issue of Contemporary Nurse. Nurse educators from Canada, Finland and the United States agreed to participate in this study by responding to an open-ended questionnaire about nursing education in their respective country. They were also invited to co-author this article.

The nursing education questionnaire was designed for nurse educators to self-report information about their respective country's nursing programs. The questions were developed to elicit information about a country's history of modern nursing education, the types of nursing education programs offered, and the political influences on nursing education. The questions were grouped together on the same topic to make the questionnaire easier to answer. The data was analyzed to compare the similarities and differences in nursing education in the three countries. The researchers believed this information would add to the body of knowledge about common standards and competencies for entry-level registered nurses to guide future registered nurse agreements between countries or multi-country licensure programs (see 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. They sent their findings to the respective nurse educators in each country to review and validate its accuracy. The results are reported below.

History

Canada

Canadian nursing education had its beginnings in the apprenticeship training of nurses in hospitals established by religious orders in what was New France. In 1874, the establishment of the first formal nursing school modeled after the Nightingale school in the United State was established in Ontario. These programs were three years in length and were the dominant model until the late 1960s (Ross-Kerr, 2003a). Beginning in 1905 The Canadian Nurses Association (CAN) as well as other professional groups recommended the movement of nursing education in educational institutions.

In 1919, five universities introduced university level courses to diploma prepared nurses. This was in response to the need for prepared nurses in public health nursing (Ross-Kerr, 2003b).The courses, which expanded to include preparation of teachers, and supervisors in nursing, became the forerunners of post-diploma nursing degree programs at the undergraduate level. The first program was established at the University of British Columbia. The program consisted of one year at the university followed by three years in a teaching hospital based program and a final year at the university. Subsequently, that model, labeled a 'sandwich' program, was introduced at several other universities (Ross-Kerr, 2003b).

In 1942, the first undergraduate basic nursing program fully controlled by a university, known as an integrated program, was introduced at the University of Toronto. Although several other universities introduced similar integrated programs, the post-diploma and 'sandwich' programs continued to be the dominant models of university nursing education until the late 1960s (Mansell, 2004).

In Canada, universities, community colleges, and hospitals are autonomous institutions with their own Boards, supported by the governments as public institutions. In 1964, a national commission on health service in Canada (Government of Canada, 1964), recommended the transfer of diploma nursing education from the hospitals to the community colleges with the closure of the 'sandwich' programs and an expansion of the basic integrated programs. By the early 1970s, the vast majority of diploma programs in hospitals were closed. Diploma level nursing education became established in the community colleges. With the elimination of the nursing service component, the programs became two years in length. As recommended, the universities converted 'sandwich' programs into four year basic baccalaureate programs and there was an expansion of the four-year basic programs (Ross-Kerr, 2003b).

The first graduate program in nursing at the master's level was established at the University of Western Ontario in 1959. That program prepared nurses in the functional areas of nursing education and administration (Wood and Ross- Kerr, 2004). Currently there are twenty-six Master's programs in nursing that prepare graduates for further education at the doctoral level with the majority clinically focused (CNA, 2005).

There are thirteen doctoral programs in nursing granting a research based PhD. The first doctoral funded program was established at the University of Alberta in 1991. The doctoral programs in nursing fall between the US and UK model. They are characterized by a small number of required courses, a firm grounding in the discipline, a strong nursing research component, a strong focus on the student/supervisor relationship, and a requirement by many that the student identify a research area prior to admission (Wood et al., 2004). There is general agreement that alternate doctoral programs such as Nursing Doctorate (ND) degree as exist in the US will not be developed in Canada (CASN, 2004a).

In the 1980s, provincial nursing regulatory bodies initiated the movement for a baccalaureate degree in nursing as the minimal educational requirement for entry into the profession. In 1989, the CNA approved a recommendation that by the year 2000 entry into the profession would require a baccalaureate degree in nursing. Strategies to achieve this goal included expansion of both the post-diploma programs and basic baccalaureate programs and expansion of graduate programs. By 2005, all but three of the ten provinces and territories in Canada have achieved this goal and the majority of new graduates hold a degree in nursing (CNA/CASN, 2005).

There are three routes to a baccalaureate degree in nursing: four year collaborative degree programs between community colleges and universities (in Quebec, the programs are five years in length), four year degree programs at the universities (three years in Quebec), and post-diploma programs of varying lengths. Eventually, the latter will be phased out. In 1988, in Alberta, the regulatory body adopted the position that baccalaureate education in nursing be required, but that position was not supported by the government. Qualified students in collaborative programs could opt for licensure at the end of three years of study. The act governing health professionals is undergoing changes and as of 2010, entry into nursing will require a baccalaureate degree in nursing (Fletcher, 2005). In Manitoba, the regulatory body was forced to rescind the requirement for baccalaureate education. The government withdrew its support under pressure from health service administrators who feared a shortage of registered nurses would occur as a result of the higher educational requirements.

In Quebec the government, while not supporting the position of the regulatory body, mandated the universities offering nursing programs to develop collaborative programs with the CEGEPs (community college). These five year programs consisting of an integrated curriculum of which three years are taken at the community college followed by two years at the university were introduced in 2001. Students have an option to write the licensing examination after completion of three years. In 2004, the government indicated that it wanted at least 50% of all graduates entering the nursing profession to have a baccalaureate degree in nursing (OIIQ, 2004).

Finland

In 1888, Professor Fredrik Saltzman, a Finnish physician, sent Anna Broms to Sabbatsbergs hospital in Sweden and to the Royal Hospital in Edinburgh to learn nursing. She became the first educated matron (chief nurse) in Finland. Nursing education started in 1889 at the New Surgical Hospital, which was part of the Helsinki General Hospital. Until 1936, the matron of the Surgical Hospital was also the principal for the nursing school at the General Hospital. The women accepted to the program had to be between 21 and 35 years of age and have at least five years of completed 'women's school' . From 1891, the course was one year, by 1906 to one and one-half years, by 1914 to two years and finally extended to three years in 1919. After graduating, the nurses were titled 'elder nurse'. This entitled them to work as head nurses and matrons in the Finnish hospitals. The matron lectured in nursing and the physicians in anatomy, physiology and bacteriology. State owned hospitals only had a head nurse on every ward and student nurses providing nursing care (Tallberg, 1991).

Baroness Sophie Mannerheim, a graduate from the Nightingale school in London, was employed as matron of the New Surgical Hospital and principal of the Helsinki General Hospital Nursing School (HGHNS) in 1904. Baroness Mannerheim was chair of the Finnish Nurses Association (FNA) from 1905-1926. In 1905 the FNA sent a nurse named Ellen Nylander to London Hospital to learn about their 'Preliminary school' (PS) and to develop a PS for HGHNS. In 1906, the FNA, supported by the influential Baroness, required the HGHNS student to study at PS before doing their nursing education at HGHNS. Because Baroness Mannerheim was both charismatic and influential person, no one (not even the State Medical Board) protested the PS requirement. The Finnish Nurses Association (FNA) paid two months of education at PS, and extended this to four months in 1919. While attending PS students studied nursing theory, anatomy, physiology, bacteriology, nutrition, cooking, cleaning, childcare, and practiced using each other and dolls (Tallberg, 1991).

By 1904, nursing education was established at seven county hospitals in Finland. Admission criteria to the nursing programs varied by hospital. These programs were six months in length. Entry age and levels of education varied from program to program. The student nurses were taught by the 'learning by doing' principle. However two of the schools tried to compete with the Helsinki General Hospital Nursing School by strengthening the admission criteria, lengthening the course to two years and offering lectures given by the matron and the physician. The students graduating from county hospitals programs were titled 'younger nurse'. They worked in the community as ambulatory nurses or in the small community hospitals (Tallberg, 1991).

In 1909 when Finland became a member of the International Council of Nurses (ICN), a federation of national nurses' associations, there was an expectation that each member would have three year nursing programs by the 1920s. This was accomplished in Finland by 1930 when all schools had a standardized three year curriculum with the last six months the students choosing a specialization, such as surgery, internal medicine, or pediatrics. All students began the training with four months Preliminary school. From 1930, all were State nursing schools, none of the programs were 'hospital based' and there was no longer a distinction between 'elder' and 'younger' nurses (Tallberg, 1991; Tallberg & Venny, 2005).

Public health nursing education that had started under private management in 1924 was taken over by the State in 1931. In 1945 a new integrated nurse-public health nurse education was started first in two nursing schools and later in four (Tallberg, 2005).

From 1957, nurses graduated after a two and one-half year program in general nursing. To obtain a specialization, they needed to have at least two years of clinical experience as nurses and take a nine month (one academic year) specialization course. This arrangement was partly dictated by shortage of nurses.

The State Medical Board decided on a new nursing curriculum in 1964 and beginning in the 1970s, the nursing schools had to comply. The Vocational Board, which in 1967 had taken over the supervision of the nursing schools from the State Medical Board, was responsible for approving the nursing curriculum (Havanto, 1989).

During the period 1987-1994, nursing education changed its admissions standards because of a reorganization of all vocational education and began admitting students after only nine years of education (middle school). The first year of the programs was general education (mathematics, languages and social sciences, psychology) and the last three years were nursing theory and clinical. Between 1994-1998, all of the vocational programs were eliminated and Polytechnic colleges began offering baccalaureate level nursing education as the entry level for nursing.

Kuopio University was the first to offer a Master's Degree in Nursing with nursing administration as a special focus in 1979, followed by Helsinki in 1983. The nurse teacher education started in 1986 at all five universities as well as the program for nurse specialist. The first PhD program was started at Kuopio University in 1980. Now there are five universities offering PhDs, four taught in Finnish and one in Swedish.

United States

In 1861 Dorothea L Dix, a school teacher from Boston with much success in treatment of the mentally ill, established a month long training program for nurses to assist with a great need for trained nurses during the civil war in the US. Many physicians disapproved of these 'ladies' as nurses and it wasn't until 1869 that the American Medical Association took the position that it was just as important to have well-trained and skilled nurses as it was physicians (Hamilton, 1996). The recommendation also included that county medical societies supervise nurse training.

It was not until 1872 when the first nursing school was established in the US at the New England Hospital graduated Linda Richards from their 12 month program. In 1873, programs were established at Bellevue, Massachusetts General and New Haven Hospitals designed after the Nightingale school in London. The Nightingale model awarded a diploma to students after a prescribed course of study. Both the success of the programs and the low cost service to the hospital involved a massive proliferation of diploma schools in the United States.

By 1909, there were 1105 hospital-based two and three-year diploma programs in the United States (Hoffman, 2004). There was no standard curriculum or accreditation of these schools. Each school was designed to meet the needs of the hospital and faculty were graduates of the programs themselves. By 1912, most of these programs were three years long (Hoffman, 2004).

In 1914, nurses were desperately needed to care for the World War I wounded and ill soldiers. The war offered many nurses a chance to advance into new areas of specialization (Cherry & Jacob, 2005). Nurse anesthetists also became a common member of each surgical team. In addition, the US Public Health Service founded earlier in 1798, flourished and established nursing services at US military outposts. These nurses were trained in providing community health care to the indigent (Stanhope & Lancaster, 2004). In 1918, the Vassar Camp School for Nurses was established to help the army fulfil the nursing shortage. These college graduates were given two years of nurses training and an army reserve commission to be activated during wartime. With the end of World War I in 1919, the program was disbanded (Cherry & Jacob, 2005).

In 1917, the first of three studies published by the National League of Nursing Education contained a curriculum outline for all nursing schools to follow. These studies recommend a standardized curriculum, job analysis to define the function and qualifications of nurses and the need for public health nurse, supervisors and nursing instructors to obtain additional education beyond that of a basic diploma.

In 1923, Yale University School of nursing was founded, followed by Vanderbilt. In 1932, the Association of Collegiate Schools of Nursing was established to promote the education of all nurses at a college level.

During the great depression, 1930-1939, when nurses were highly affected by massive unemployment, the American Nurses Association launched a movement to give up hospital-based nursing schools and supported hiring only graduates from reputable universities. This was met with much resistance by the hospitals (Cherry & Jacob, 2005).

In 1937 National League for Nursing Education's Curriculum Guide for Nursing schools called for two major changes to the curriculum: one was the primary function of the nursing school was to educate the nurse, not provide service to the hospital and the other was the nurse was to serve the entire community not just the hospital (Kalisch & Kalisch, 2003).

Due to the post World War II nursing shortage, poor working conditions and political turmoil the National Committee for the Improvement of Nursing Services (NCINS) was formed and was opposed by National Organization of Hospital Schools of Nursing that had not been accredited by the NCINS. In addition, The Subcommittee on Tests of the Committee on State Board Problems of the National League of Nursing Education met and recommended that the league assist in adopting a State Board Test Pool. By 1950, all the states had joined the pool and nursing became the first profession in which all applicants used the same national licensing examination (Kalisch & Kalisch, 2003).

Pioneered during the 1950s as a doctoral project by Mildred Montag, Associate Degree Nursing Programs were established to meet the desperate need for nurses (Roberts, 2002). By the mid-1960s Associate Degree Nurses out- numbered the nurses with baccalaureate degrees and diploma programs (Catalano, 2003).

The Catholic University of America in Washington DC offered the first Masters degree in nursing in 1935 (Zerwekh & Claborn 2004). There are currently more than 330 master's programs accredited by the Commission on Collegiate Nursing Education or by the National League for Nursing Accrediting Commission. These degrees vary from a Master of Science in Nursing, Master of Nursing Degree, Master of Science with a major in nursing or Master of Arts with a nursing major.

Doctoral education began in 1933 at the Teachers College, followed by Columbia University in 1933 and at New York University in 1934. Today there are 85 institutions are offering doctoral degrees to nurses. Over 80% of these are a PhD in nursing with the other 20% being either a Doctorate of Nursing Science or Doctorate of Education (Ketefian, Neves & Gutierrez, 2001).

Types of Nursing Programs

Canada

As of 2005, there are three routes to initial licensure or registration as a registered nurse. They are the diploma in nursing for nurses who entered the profession prior to 2005 or residing in the provinces of Alberta, Manitoba or Quebec; the baccalaureate degree in nursing granted by a university (recognized by all provinces/territories); and a master's degree in nursing for holders of non-nursing degrees who complete a three year graduate program in nursing (McGill University offers the only program of this type in Canada). The academic admission criteria vary by university, but a trend since the 1980s is for more candidates with a degree in another discipline to apply to nursing. Such candidates are provided an accelerated program of studies leading to a baccalaureate degree, (other than at McGill, which offers qualified candidates an option to enter a master's program). As accelerated program applications increase, several universities are restricting enrolments into basic baccalaureate programs to this applicant pool, thus, decreasing the length of the nursing programs. Licensure as nurse practitioners is provided in several provinces after additional advanced education. The level of education varies from post-baccalaureate to graduate. In addition to studies in nursing, undergraduate nursing students are required to take courses in the biological, health and social sciences, humanities, and arts that are integrated throughout the four year curriculum. Competency in English is required, except in the province of Quebec, which requires all registered nurses to have competency in oral and written French. The educational approaches range from didactic classroom lectures to problem-based small group, to self-directed learning. However, all university graduates in nursing are expected to acquire knowledge and skills that enable them to work in diverse settings, understand the broad determinants of health, understand research, be able to critically appraise research literature, to make informed judgments with respect to utilizing findings in practice, and to be self-directed lifelong learners (CNA/CASN, 2005). Diploma prepared nurses are prepared primarily for the acute and chronic care institutional settings. The learning resources range from textbooks, CD ROMs, videos, simulated patients, to clinical skills learning laboratories using all current levels of technology. Extensive learning resources are available through university libraries and the interlibrary connections as well as through the internet. Accessibility in many programs is enhanced through web-based and on-line distance education. Several programs are completely on-line based. Computer technology is standard usage in nursing education at all levels.

Clinical education is under the control of the university faculty and there is extensive use of nurse clinicians as preceptors. The number of hours allocated to clinical courses varies by pro- gram, but the norm is to have the clinical courses increase as the students move through the curriculum. Clinical facilities range from acute care hospitals to pre-school kindergarten to community health services. Many programs provide students with an opportunity to complete an intensive clinical experience in the Northern health services, international health, or in specialty areas (CASN, 2004b).

Nursing graduates practice in a broad range of settings ranging from highly complex acute care hospitals to rural and urban community health services; to care for patients at all ages and with a range of diseases; and to engage in health promotion and disease/illness prevention at the level of individuals, groups and communities.

Responsibility for regulation of the profession of nursing rests with provincial/territorial regulatory bodies. In all but one province, Ontario, the regulatory bodies are also the professional associations. In that province, the mandates of regulation and promotion of the profession reside in separate organizations.

The regulatory bodies determine the competencies required for registration or licensure as well as setting and administering the examinations. The educational programs have responsibility for ensuring the graduates have attained those competencies. The national professional nursing organization has no regulatory powers. However, its testing service in collaboration with the provinces developed the Canadian Registered Nurse Examination (CRNE), and all provinces and territories except Quebec use the CRNE. Expertise from the educational sector is used in developing and revising the CRNE.

Quebec opted out of the CNA in the early 1970s, and developed and implemented its own licensure examinations. There is reciprocity across the provinces. The universities and provincial ministries of education must approve all new nursing education programs. The regulatory bodies have a system for approval of the educational programs but the educational institutions are autonomous and establish admission criteria, curriculum, learning outcomes, and requirements for promotion and graduation.

The Canadian Association of Schools of Nursing (CASN), a national organization, developed and administers a program of accreditation for baccalaureate programs in nursing. The CASN is in the process of developing a program of accreditation of graduate programs. Accreditation is a voluntary process; however, in several provinces the regulatory body accepts accreditation in lieu of approval (CASN, 2004c).

In all provinces, students in the university sector pay tuition, amounting to approximately 25% or less of the cost of their education. In all provinces students pay tuition at the community college level, except in Quebec, where there are no tuition fees at this level. Tuition at the colleges is less than at the universities. The federal government influences education through transfer payments to provinces and a scholarship program for students.

Nursing in Canada is primarily a female profession (women constitute 94.7% of the nursing workforce).The number of men (5.3%) is highest in the province of Quebec (9 %). Men work predominantly in medical/surgical, psychiatric, critical care, emergency, and administrative areas (CIHI, 2004). Nursing in general and educational programs in particular direct their marketing to men as well as women.

Finland

Polytechnic colleges offer baccalaureate degrees in nursing. The three and one half year baccalaureate degree nursing programs are 210 Ects (European credit transfer system) of which 75 Ects are clinical studies. The courses consist of basic studies (12.75 Ects), dimensional health (6.75 Ects), health, and social care from a multi professional perspective (12 Ects) and bachelor's theses followed by a maturity test. The bachelor's thesis gives students experience in applied research work. The maturity test is written on the topic of the thesis. Students study a foreign language, in addition to Finnish and Swedish. Finland is a small country in Europe so students must know other languages.

The type of nursing courses include: basics in clinical nursing, health and social care from a multi professional perspective, children's, mothers and gynecological nursing, home care, internal, surgical and peri-operative nursing and psychiatric health and nursing care. An alternative professional study, an elective specialty course, includes pediatric, internal and surgical nursing, peri-operative nursing or psychiatric nursing.

The Ministry of Education approves the Polytechnics nursing curriculum and accredits the programs. Responsibility for regulation of the profession of nursing rests with the Ministry of Social Affairs and Health.

To become a public health nurse, the students take an additional semester. They earn both a Bachelor of Nursing and a Bachelor of Public Health. A Bachelor of Paramedics is a four year program. A midwifery program is an additional year of courses for total four and one half years. They earn both a Bachelor of Nursing and a Bachelor of Midwifery.

During the 1930s, teaching nursing changed from it being taught by matrons and physicians to nurse teachers. Nurse teachers needed to complete a three-month program on nursing education. In the 1960s, the first formal two year nurse teacher program was established and required in all programs by 1996 (Havanto, 1989). Some nurse educators have a Licentiate (a degree between Master's and Doctorate degree and one year of theoretical study and a thesis that is a little 'lower' than a doctoral thesis) or a doctoral degree.

When students are in clinical, nurse-teachers supervise as well as staff nurses when the nurse-teacher is not available. Colleges must pay hospitals for the right for student clinical placements.

In 1909, The Finnish Nurses Association started to publish nursing textbooks and in 1944, the Foundation for nursing education took over the assignment until 1994. Now many publishers produce nursing textbooks and in some courses English textbooks are used. Students buy their textbooks or borrow them from the library. Today nursing journals, CD ROMs, videos, and the Internet are in common use as educational material.

Students attending Polytechnic colleges pay no tuition or fees. This allows anyone, regardless of one's economical background, to become a nurse.

Ninety (90%) of the nurses are female. Three Polytechnic's students unions have together started the 6mix (pronounced in Swedish sexmix) project. The purpose of this project is to promote equality between sexes by having more girls choose a technical profession and more boys a health care profession. With the help of a theatre group, web based and written material, they work with students, parents and teachers to try to change peoples' attitudes toward which professions are more suitable for girls and which for boys.

There is no licensing examination for registered nurses. When students graduate, they automatically become Registered Nurse. The regulatory bodies determine the competencies required for registration as registered nurses. The Finnish national professional nursing organization has no regulatory powers.

United States

There are five ways a student can become eligible for registered nurse licensure: the associate degree program of two years, diploma program of three years, baccalaureate degree of four years, entry program following a baccalaureate degree in another discipline of two years and the newest program of the master's entry program following a baccalaureate degree in another field. The education of nurses may be through public or private institutions and fees are solely the responsibility of each student. The associate degree programs graduate by far the largest group of students graduating nearly 60% of all nurses. Baccalaureate Degree nurses represents 36% of the nursing population while diploma graduates are the least at 4% (Catalano, 2003).

There is no standard admission criterion to nursing programs either across the US or within states. Admission to programs may include entrance examinations, grade point averages, letters of recommendation, previous healthcare experience, and knowledge of a second language or a lottery type system depending on the admissions requirements of the programs.

Nursing curriculum in all programs includes theory and practice. The curriculum, outlined by The National Council of State Boards of Nursing (NCSBN) Model Nurse Practice Act, is more detailed in each particular state's Nurse Practice Acts published by each states Board of Registered Nursing. The curriculum includes legal/ethical issues, leadership, biological, physical, social and behavioral sciences to provide a foundation for safe nursing practice. Supervised clinical experiences in all programs include the prevention of illness and the promotion of health across the lifespan in a variety of settings. These settings include obstetrics, pediatrics, geriatrics, mental health, community/public health, and medical/surgical nursing (Board of Registered Nursing 2005).

Faculty qualifications and faculty to student ratios, which are based on safety rather than numbers, are also outlined in each states nurse practice act. The minimum education level for full-time faculty as outline in the NCSBN Model Nurse Practice act is a Masters degree in Nursing. Universities generally require a Doctorate level preparation for tenured faculty.

Textbooks are required for most nursing courses as well as the prerequisite course and are readily available to all students and faculty.

National Council Licensing Examination for Registered Nurses (NCLEX-RN) is the national examination nursing graduates must pass to become a registered nurse. Graduates from baccalaureate programs also qualify and may apply for a Public Health Certificate with no further examination. Advanced practice registered nurses (APRNs) require additional education and licensure including Certified Registered Nurse Anesthetist, Certified Nurse Midwife, Certified Nurse Specialist or Nurse Practitioner (Hoffman, 2004).

The National Council of State Boards of Nursing (NCSBN) is a non-profit organization comprised of members from all fifty states and five United States territories whose purpose is to provide an organization for all the fifty state boards to counsel together on common interests affecting public health and welfare, including the development of the NCLEX (NCSBN, 2005). However, each state is responsible for registering qualified registered nurses, accrediting nursing schools, and revoking licenses of nurses found to be unsafe to practice by protecting the public through the administration of the Board of Registered Nurses.

Females continue to dominate the profession with nearly 90% of all nurses being female. Male nurses are employed in all areas of nursing (Kalisch & Kalisch, 2003).

Nursing continuing education is required by some states following initial licensure of a registered nurse and fifty units every two years is required for the advance practice nursing license (NCSBN, 2005)

Challenges for Nursing Education

Canada

The negative aspects of the nursing work environment such as the decrease in number of fulltime positions, and high rates of stress disability and illness negatively impacted on enrolment in nursing programs in the 1980s. The country is experiencing a shortage of RNs and efforts have been made to increase enrolment. The aging of faculty and the paucity of faculty prepared at the PhD level are impediments to rapid increases (CASN, 2004 a).

Nursing education is facing a number of challenges in the 21st Century but requiring the baccalaureate degree in nursing as the level of educational preparation for entry into the profession is a major achievement. Having a more highly educated workforce will impact positively in the health of the population as well as in the image of nursing as a profession.

Finland

The Ministry for Social Affairs and Health, who has the responsibility for the health care and the patient's security, recommends that registered nurses should have 4-10 days continuing education yearly. The Finnish Nurses Association is trying to have legislation that makes nursing continuing education a law. Polytechnic colleges offer continuing courses, such as courses in dialysis in diabetic care, transplantation care.

Nursing is highly respected profession by the Finnish people. There is a shortage of nurses and nursing students, but enrolment has been improving the past few years. During the Finnish economical recession in the 1990s many nurses moved to other European countries, such as UK, Germany, Norway or Denmark (Finland is a bilingual country with about 6% with Swedish as their mother language which makes it easy to work in the other Nordic countries, where the language is quite similar), and even to Australia. Currently registered nurses have good job-opportunities in Finland.

In 1995, Finland joined the European Union (EU). Finland's nursing programs have been following the European Union 'principles' for homogenizing the European nursing education to ensure that all nursing programs are equal in length and the theory/practice cover the same content. In fall 2005, Finnish nursing schools began following the Bologna convention, which means a uniform European nursing education. The European Network for Quality Assurance in Higher Education has been established to ensure common standards for the outcomes.

A challenge for nursing education and practice is to be able to provide evidence-based client centered nursing, and to keep pace with the new developments in nursing and medicine.

There are ongoing discussions among nursing leaders of allowing nurses to enter doctoral studies directly after completion of a Bachelor in Nursing to help with the faculty and nursing shortages. Today a master's degree is needed before starting doctoral studies.

United States

The most serious problem facing nursing is the nursing shortage. There is both a shortage of nursing faculty and an aging of the faculty. There are not enough faculty members to educate the number of nurses to meet the nursing care needs of the public. Additionally, only 82.5% of the 2.5 million registered nurses are working (Peterson, 2001).

Both the American Nurses Association and the National League of Nursing support the baccalaureate degree as the minimal level of education for entry into practice, however, the proliferation of Associate Degree programs to meet the nursing shortage are an impediment to this goal.

Comparisons in Nursing Education

Canada, Finland, and United States, have many similarities and some differences in nursing education. All three countries have a long history and struggle towards the improvement of nursing and nursing education. Each country is moving towards the minimum educational level of a baccalaureate degree for all nurses. This has been a difficult process for political and practical reasons. The basic levels of nursing education vary only slightly. Canada has nearly all BSN level programs except for three provinces, which are leaning in this same direction. Finland has all BSN graduates from Polytechnic colleges. However, the United States continues with associate, baccalaureate, diploma nursing programs and the newest on the scene an entry level Masters degree for those with a previous bachelor's degree in any other field.

Some form of admission criteria exists in all three countries but varies greatly. Admission may be by examinations, previous educational accomplishments or meeting minimal grades in prerequisite non-nursing courses. The nursing curriculum requires humanities, health sciences, social sciences and nursing theory and clinical across the lifespan. All three countries have textbooks and different teaching modalities in which to delivery curriculum.

Differences include Canada and the United States requiring their nursing graduates to pass licensing exam whereas Finland does not. The students who graduate from Finnish schools are required to learn at least three languages and neither Canada nor the United States have a language requirement, except Quebec providence, which requires French (and not English).

All three countries have other nursing advanced specialty degrees and both Master's and Doctorate degrees available. Canada, however, does not provide or support the Doctorate of Nursing Science, which is supported in the US.

Each country is experiencing nursing and nursing faculty shortages, though Finland is recovering from its nursing shortage, for economic reasons, by making education available for all students who want to become nurses.

A major challenge for all three countries is the political influences that affect nursing. Governmental regulations and political factors will continue to have a major impact on the future of nursing and nursing education.

Limitations of the Study

The limitations of this study included the small sample size of the three countries. 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 Finnish language, which may have lead to misinterpretations or misunderstanding of information sent by the nurse educator, and hindered their ability to read articles in those native languages.

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 in various countries. This article has provided information on nursing education in Canada, Finland and the United States. 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. This study is part of a larger research project investigating nursing programs throughout the world.

Discussion

The problem of the nursing shortage is apparent all six countries participating in this study. Each country has made an effort to more towards a baccalaureate education as the entry point for nursing however realizing this will add to the problem of too few nurses. Nursing continues to struggle with nursing-based curriculum moving away from a medical model and towards a critical thinking nursing model. Each country has had an evolution of nursing towards a stronger university centered curriculum and away from a hospital-based nursing program. A variation is apparent in entrance criteria, student- faculty ratios, availability of educational materials and national licensing examinations.

Adding to the challenge is too few nursing faculty members. All six countries have limited Masters'-qualified faculty and even fewer that are Doctorate-qualified. This compounds the problem with a medical-based curriculum by utilizing physicians to augment faculty.

In order to assist with the global mobility of nurses a mechanism of evaluating nursing curriculum in and out of the classroom is essential. This study is just the beginning to making connections in identification of both similarities and differences in nursing programs worldwide.

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