In China, education at nursing and other colleges is always changing, requiring new ways of thinking. Activity must be adjusted to the prevailing times so it will not be trapped in old patterns. For nursing education, change has meant giving opportunity for diplomas and bachelor's degrees. Some schools now have the authority to offer postgraduate studies to obtain master's degrees. Other prominent changes concern the students' backgrounds and an adjustment to the Chinese labor market. When nursing education is moved toward academia, several problems will be brought to the fore (Andersson, 1999). Among other things, nurse educators will be required to teach from an adult pedagogical or academic perspective (Burnard & Chapman, 1990). If this change is not made, there will be no substantial change in the character of nursing education. To meet educational changes, teacher competence is considered to be of strategic importance (Jiang & Li, 2000). In this article, discussion focuses on the view of the history of the nursing education program and its future.
Traditional Chinese medicine (TCM) has a history of several thousand years. In those times, practitioners of TCM provided cures, herbal drug therapy, and long-term care by the same person. Actually, the theories of TCM and traditional Chinese nursing (TCN) are almost the same, both stem mainly from practice and have been enriched and expanded through practice. The earliest extant medical classic in China, Huangdi Neijing (Canon of Medicine), was compiled between 500 and 300 BC and is a summary of the TCM and TCN, such as: the concept of the organism as a whole, or Bian Zheng (overall analysis of signs and symptoms); Yin-Yang; the five elements of the human body; channels and collaterals; qi (vital energy) and blood. Huangdi Neijing also addresses basic knowledge concerning nursing; following Neijing, there appeared quite a number of treaties on traditional nursing in different dynasties (Lin, 1999). Nursing as a profession began in China in 1884 when some hospitals were established in Shanghai and Fuzhou. Since then training courses for nurses also came into being.
The first nursing school opened its first class in Fuzhou in 1888. In 1921, a university nursing school in Peking University was established to prepare nursing instructors and public health. Since then more than ten colleges and university nursing schools were established for the whole country where most of the nurses were trained in a three-year program at hospital-run schools. The role of the nurses was conceived as that of caring for the "hospital family." All the departments of the hospital, from wards, operating rooms to store rooms and kitchens, depended upon the continuous presence of nurses. Like mothers in a household, nurses were responsible for meeting the needs of all the members of the hospital family-from patients to physicians. In 1909, the Chinese Nursing Association (CAN) was established. Soon in 1922, the membership joined the International Council of Nurses (ICN) (Wang, 1997). At that time, the Chinese nursing education was unbalanced in its development. Hospitals and schools of nursing were scattered in the east coastal regions in China. The CAN served as the sole accrediting agency for all levels of the nursing education program.
In 1949, China had more than 30,000 nurses and 183 nursing schools. From 1949 to 1951, with rapid development in the health field, the government established large numbers of secondary nursing schools to prepare nurses. Nursing education under the leadership of both the National Ministry of Education and the National Ministry of Public Health, had a unified system and curricula. By the time the program needed 3 years, nurse educators taught subjects such as nursing, ethics and management, and physician educators taught medicine and biomédical science including anatomy, physiology, pathology, microbiology, biochemistry, and pharmacology.
Unfortunately, in 1951, college and university nursing schools were discontinued for financial reasons. However, head nurses in hospitals or teachers in nursing schools conducted long- and short-term training programs to prepare nurse educators and head nurses. During the decade of the Cultural Revolution (1966-1976) when general education was interrupted, almost all the nursing schools were closed, and faculties were dispersed. For a period of 4 to 5 years, there was no training of nurses. A nursing shortage then ensued. The hospital administration was in a confused condition. Both the quality and quantity of nursing care were in deterioration (Lin, 1992). Therefore, from 1970 to 1977 in response to this situation, short courses for training nursing staff were organized in some hospitals. However, the quality of nursing at that time was not well developed to meet the health needs of the people.
In 1978, China adopted the policy of opening up to the outside world, which brought the bright future and prosperity for the reform. Nursing education was gradually standardized. The Bureau of Education in the Ministry of Health established the educational system and the teaching requirements again. Some provinces and cities such as Tianjin, Shanghai, and Beying established their independent nursing schools with their own budget and teaching facilities. Some nursing schools organized training classes for teachers responsible for the fundamentals of nursing while local nursing associations in some provinces and cities organized advanced training classes for nursing teachers (Lin, 1992).
In the 1980s, the Chinese government witnessed rapid growth of higher education in developed countries. In 1983. the first university nursing school reopened at the Tianjin Medical University. The 30 students who passed the university entrance examination would study nursing science and technology for 5 years for a bachelor's degree. The objective of the university nursing school was teaching, research, administration, and service. In January 1984. the National Ministry of Education and the National Ministry of Public Health held a meeting to discuss the educational system and the curriculum for university nursing schools. As a result of that meeting, by 1986, 8 university nursing schools had been instituted. Graduates were permitted to go abroad to study for master's and doctor's degrees in order to raise the level of nursing education. The program for nursing as a profession had different types of training. The majority of nursing schools were still the secondary nursing schools. The nursing students could be senior or junior middle graduates and get 3 to 4 years of liberal education but the same professional training. At the same time, some nurses who graduated from the secondary nursing schools were given the chance to pursue continuing education and reach the college nursing school level. By 1987, there were more than 30 schools for continuing education.
Because of the current open policy in China, nursing education has made many of the following positive and substantial changes.
Nursing Recognized as a Profession
During the 1950s and 1960s, there was disagreement as to whether nursing is a profession or an unstable vocation (Lin, 1992). At that time, many well-qualified nurses promoted their social status to become a doctor instead of a nurse. It aroused bewilderment among the nurses and presented an erroneous image of nursing to the society. In the years of reform, the government reaffirmed that nursing is an independent profession that requires well-qualified personnel. At the same time, nurses were awarded the academic title by the code of the National Ministry of Health, in accordance to their educational background, their ability in nursing administration, and their skill in nursing practice. Nursing and medical professionals are on equal status for receiving such an honor. In addition, the government took measures to encourage high school graduates to enroll in schools of nursing and called back those who had already engaged themselves in the medical field to resume their original nursing profession.
Increased Number of Training Institutions
According to an investigation by the Chinese Nursing Association, in 1999 there were 67 university nursing schools, 35 college nursing schools, 500 secondary technical nursing schools, and master's degree programs in 15 universities. Continuing nursing education, life-long learning, swept over the whole country. With the increased pace of the reform drive, nursing education began developing rapidly. There were 1,288 million registered nurses in 1999. Three educational programs now exist that prepare graduates for licensure as a registered nurse (RN).
Secondary Nursing School Program
The secondary nursing school program is available in secondary medical schools and requires three to four years to complete. The curriculum includes nursing courses as well as courses in the biological, physical, and behavioral sciences. These programe are designed to provide students with technical nursing knowledge and skills. Technical nursing graduates are not eligible for entrance into graduate programs and if they decide to change career direction, they must first earn a baccalaureate degree.
College Nursing School Program
The college nursing school program is available in the medical colleges and requires two to three years to complete. The curriculum includes a combination of nursing (theory and practice) with college level general education courses in the liberal arts and sciences. The college nursing school programs are designed to educate students who will give patient-centered nursing care in hospitals as general duty or as staff nurse. Graduates of these programs are expected to function with intelligence and skill in the more predictable or recurring patient care situations that require a less broad knowledge base. Like secondary nursing graduates, college nursing school graduates are not prepared for entrance into graduate programs and if they decide to change career direction, they must first earn a baccalaureate degree.
Baccalaureate Degree Program
The baccalaureate degree program (BSN) is available in universities. This program requires 4 to 5 years to complete and includes professional nursing basic courses, special clinical nursing courses, public health nursing courses, humanity science, and others (including courses of administration, education, research, and humanities). The teaching hours of those four courses occupy 13.35%, 21.66%, 4.22%, and 3.97% respectively. The nursing courses build on the knowledge gained from science and humanities so that the baccalaureate graduates achieve a broad understanding of nursing and related sciences as well as the basic nursing skills.
Baccalaureate graduates are prepared to give highquality nursing care to patients and their families and to direct the nursing care given by the nursing team members with them. Graduates are qualified for employment in general nursing practice in any setting where professional nursing care is given to hospitals and community health agencies of all kinds: the military, cop, or other governmental nursing agencies. Baccalaureate graduates are expected to enter the work force at the beginning level of competence, eventually managing complex, unique situations that require broad theoretical knowledge. This program also introduces its graduates to the basis of leadership, management research, teaching, and service as well as provides them with the educational background required for graduate study in nursing.
The baccalaureate program is for the person who has educational and career goals consistent with the philosophy of professionalism; the person who recognizes a need for additional learning after graduation from the basic program and assumes responsibility for continuing professional growth and expertise; and the person who desires advanced study to obtain a master's degree.
Advanced Study in Nursing
In China, advanced study in nursing occurs at the master's level of education. The master of science in nursing (MSN) degree prepares professional nurses to assume leadership roles in patient care activities, teaching roles, or management of patient care services within hospitals or community agencies. This program requires 3 years to complete. In contrast to the baccalaureate prepared nurses who are généraliste, specialty preparation occurs at the master's degree level.
A doctoral program has not been promised by the National Ministry of Education. A doctoral degree in nursing would provide opportunities for aspiring academics to develop the knowledge and skills needed for good teaching. It is also needed to provide the opportunity for some portion of the nursing academic community to conduct scholarly research in nursing.
FUTURE OF NURSING EDUCATION IN CHINA
The value of considering our historical accomplishments cannot be emphasized enough, particularly as we search for today's answers and ponder tomorrow's questions. Because of our heritage we are able to understand the solution to many of today's nursing education concerns. All will assist us in the preparation for meeting tomorrow's needs. There are many opportunities and challenges that Chinese nursing educators will face in the future.
Strengthen Educational and Credential Systeme
The system of nursing education in China has evolved in response to social needs. Nurse educators must have an academic degree because this level of teachers emphasizes research, theory development, and development of cognitive skills in nursing education and practice. Nurse educators who recognize that current students have acquired more theoretical background and more academic views from their senior middle school, are pursuing higher education. The main goal of this education is to obtain a master's degree in nursing or social science. The well-educated faculties who have a masters' degree are given the authority to plan education, design curriculum, decide the content and courses as well as examine the students. The quality of nursing education is much better than before. Most of them will have a PhD and assert that only through academic studies can one develop an analytic approach to situations, use or conduct research, or develop the ability to follow knowledge development. They also believe that they can change nursing education from technical training to an academic education. These nurse educators believe that university education enables learning to continue throughout life without limit between their private and professional lives (Chen & Liang, 1999). When these educators enter the university nursing school, their priorities are first to conduct research; second, to supervise students and other faculty in small-scale research projects; and third, to teach the nursing students.
Expand the Scientific and Research Base
China has experienced a rapid increase in technology over the past 20 years, which has helped health care professionals to extend the life process. It is anticipated the research outcome will highlight the importance of nursing academics (Mitchell, 1999). As a result of the education reform in China, nursing education changed from a biological paradigm to a humanistic or holistic paradigm. Nurse educators use their research skills to enhance students' view of health and shift from being nurse-centered-where nurses are obliged to impact clients with a set of health practices- to being patient-centered where the patient is accepted as an individual with a unique background. Finally, the students reach a reciprocal relationship with the clients, where the nurse and clients are viewed as partners in working towards the goal of health.
There is always room for challenges and new experiences among the nurse educators. Through research we must continue to expand efforts to demonstrate that nursing interventions can help individuals maintain a state of wellness, and during times of illness make the difference in patient outcomes. Through nursing research we will continue to translate the results of biomédical research and bring them to the bedside to help health care providers care for patients in a cost efficient, cost effective manner. We have an obligation to help our aspiring academics develop some solid grounding pedagogical theory and research to learn more basic precepts of teaching and to explore alternative approaches to instruction that may result in improved learning outcomes (Tanner, 1999).
Emphasize Traditional Chinese Nursing Education
Since the foundation of the People's Republic of China, many hospitals of TCM have been established. Therefore, the nursing of TCM has gradually become a unique science and its characteristics have been inherited- the diagnosis, treatment, and nursing of TCM are based on the holistic concept. A nurse of China must learn a unique nursing concept and master it skillfully. Today, these techniques are further developed such as: acupuncture therapy, moxibustion, piercing method, incision method, cupping method, scaring moxibustion, tuina method, scraping method, fore needles, plasting method, medical compress method, and so forth. In addition the activities of medical care such as breathing exercise, Taijiqun, Banjin animal gesture exercise are instructed by nurses. AU of these are also the unique characteristics of the nursing of TCM (Lin, 1999). Efforts should be made by us to create a Chinese nursing theory and model.
Emphasizes the Nursing Experience and Practical Knowledge for Nurse Educators
As nurse educators, we have to master the working operations and methods that are part of the vocational function. To develop competence in nursing subject matter we should use practical knowledge to prepare lessons, using our nursing experiences as a knowledge base so that we can tell students how it really is to be a nurse and how nurses actually work. We can teach students how to care for patients with specific problems, how to master new technology, how to establish good relations in nursing, and how to use drama in nursing education. We can help our students use their budding skills of critical thinking and their rudimentary understanding of research to become knowledgeable participants in practice. We can find what has to be taught in class and what has to be taught in the hospital. We should work as nurses at night or some days every week in the hospital so that we can develop broad practical knowledge because nursing is primarily a practice profession requiring manual dexterity, a kind heart, and scientific knowledge (Andersson, 1999).
Reform Nursing Education
Chinese educators are all experiencing the revolution in higher education. Access cost, quality and profit are rapidly becoming part of academic culture as well as they are integrated into health care. The revolution in health care requires the educational preparation of nurses with more skills and nursing educational innovation as well. The nursing program is an innovative project for future nursing. How can we reform our teaching-learning strategies and what can we expect of our students so as to become cognitive and technical as well as emotionally competent? We need to incorporate the competencies associated with critical thinking, intelligence, and emotional control into the expected outcome of the curriculum (Bevis & Watson, 1989). Through teaching we expect our students to be self-confident; know their strengths and limits; maintain control of their emotions; be trustworthy, flexible, and active; be comfortable with new ideas and changes; have initiative, drive, commitment, and optimism; be accountable for their own performance, and do one's best. These competencies involve more than socializing new graduates or guiding them to become responsible members of the nursing profession. These competencies are less about the profession itself than about responsibilities of work and personal commitment to a professional lifetime of learning (Bellack, 1999). Thus, we need research projects concerning how to nurture students' abilities in critical thinking and emotional intelligence and how to create ways to measure achieved competencies as a graduation checkpoint, just as we do with cognitive and technical skills. We will do a better job of integration expectations related to critical thinking and emotional competence through the curriculum.
To date, cognitive understanding and technical skills are far from being sufficient in the complex profession of nursing. As nurse educators, we should be responsible for our students, for their potential employers, and most importantly, for the public. We must ensure that they will acquire the personal and social skills associated with critical thinking and emotional intelligence; thus, they will be able to use their cognitive knowledge and technical expertise to full benefit (Bellack, 1999).
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