The demand for higher education has increased worldwide and the response has been an impressive expansion of educational offerings both within and across countries. Education has been made more accessible through online offerings and the development of onsite, external campuses in foreign countries. In recent years, there has been a proliferation of educational courses that target international clientele. This has led to concerns about quality and consistency and also the need for international standards of education.

The purpose of this manuscript is to emphasize the necessity of common educational standards for nurses in a globalized world. Common standards are crucial in regulated professions, such as nursing in which lives depend on the possession of specific competencies. This article will define and describe globalization and the internationalization of education, discuss the exporting of education, nursing education, identify the challenges and current solutions related to nurse migration, and present current standards and future trends in harmonizing nursing education internationally.

Globalization and the Internationalization of Education

Globalization refers to the growing integration of economies and societies around the world, including the accelerating mobility of goods, services, labour, technology, and capital (Government of Canada, 2007; International Monetary Fund, 2008; Smith & Smith, 2002). It is not a new phenomenon; rather it is a long-term process that has waxed and waned over the centuries. The present phase of globalization differs from earlier phases in the speed with which it is occurring, as new technologies enhance communication and facilitate the circulation of information, resources, and people.

The development of a knowledge economy has made intellectual capital a valuable possession. The term internationalization has been widely used in political science and government relations for many years, sometimes synonymously with globalization. More recently the term has been adopted by other disciplines, including the education sector (Knight, 2003). Applying the term to education, Knight has defined internationalization as “the process of integrating an international, intercultural, or global dimension in the purpose, functions, and delivery of postsecondary education” (para. 4). She has suggested that globalization is the impetus for the internationalization of education.

Evolving technologies are transforming both the formal and informal acquisition of knowledge. Information is accessible electronically; and people with common interests, e.g., students, researchers, and innovators, exchange knowledge freely via the Internet. The development of a knowledge economy has made intellectual capital a valuable possession. Consequently, knowledge production through education has become an increasingly competitive industry (World Bank, 2002, 2008). Education has become a business in the globalized world and is seen as both an investment and an export commodity. Educational entrepreneurs invest in students as they serve those seeking higher education credentials. When education is “marketized,” the concepts of business become more pronounced, as noted when learners are viewed “as customers rather than participants” (Smith, 2002, para. 24).

Exporting of Education

Exporting of education is occurring in various countries and disciplines. However, such exportation is not without its challenges. This section will discuss the exporting of education both in higher education in general and specifically in nursing.

Exporting of Education Throughout Academia

There is a worldwide demand for higher education due to the increasing labour market needs for highly skilled workers, such as nurses. The United States (US), Britain, and Australia are the three leading exporters of higher education, but other developed countries also play a part (Bollag, 2006, Shepherd, 2007). In the US, education and training rank among the nation’s top service exports (Lenn, 2002; Lewin, 2008). The most rapidly growing areas for transnational education are information technology, management and business administration, engineering, international law, medicine, and the nursing specialties (Didou, Aupetit, & Jokivirta, 2007; Lenn, 2002).

Exported educational services are delivered in various ways: (a)  as students travel abroad to receive their education; (b) as education is delivered to them through distance learning; and (c) as educational institutions from one country provide onsite classes in another country, often through establishing branch campuses and/or franchises (King, 2006; Knight, 2006; Machado dos Santos, 2000).

Colleges and universities in developed countries engage in various partnerships. Some partnerships involve mutually beneficial exchanges of faculty and students. In other arrangements, faculty members from one university are contracted as instructors or consultants to establish new departments in an overseas institution.

More than ever before there is a tremendous variety of educational offerings--some quality, some not. Some education offerings are provided through the financial support of aid agencies or development funds. Others involve for-profit organizations engaged in education. These for-profit schools are funded by private developers, often with the specific goal of exporting students to meet the employment demand in other countries. The proliferation of for-profit schools has led to concerns about curriculum quality and the need to standardize professional education (Larson & Vincent-Lancrin, 2002; Smith, 2002). More than ever before there is a tremendous variety of educational offerings--some quality, some not (McBurnie & Ziguras, 2007; Verbik, 2006; Vignoli, 2004). 

The types of programs and partnerships that educational exporters set up abroad are often influenced by national policies and the degree of national development. In the Middle and Far East, countries, such as United Arab Emirates, authorize the establishment of foreign campuses locally, while China negotiates with foreign universities to establish joint degrees (Lenn, 2002). Educational centres in emerging economies are now ceasing to act as agents for foreign universities and are beginning instead to compete with them, offering their own programs and services abroad (Ham & Ham, 2006).

Exporting of Education in Nursing

Despite international differences in nursing education and practice, a number of mechanisms allow nurses to migrate throughout the world. In some source countries, there is a deliberate policy of educating nurses for export. This investment in human resources can result in generous remittances to the home country. A strategic method of profiting from “surplus human resources” is to prepare migrants to find jobs abroad and contribute to the economy of their home country through remittances to family members. In developing countries, educated but underutilized workers are among the first to migrate when opportunities become available to them (Abella, 1997; Baumann, Blythe, Rheaume, & McKintosh, 2006; Blythe & Baumann, 2008).

In the 1950s, the Philippines began to prepare nurses for export, mainly to the US (Brush & Solchalski, 2007; Choy, 2004). Educated in English with American-based curricula, Filipino nurses have migrated to the Middle East and throughout the developed world. The Philippines Overseas Employment Administration has reported that nearly 88,000 nurses left the Philippines between 1992 and 2003, but this may be an underestimate (Perrin, Hagopian, Sales, & Haung, 2007). According to one source, the number of nursing schools in the Philippines has “increased from 170 in 1999 to 470 by 2005” (Alvez Tan, 2006, slide 4).

Following the example of the Philippines, the Indian government also supports the export of nurses (Healey, 2006, Thomas, 2006). The importance of this nurse export business is reflected in the rapid growth of nursing schools in India (Thomas, 2006). Many groups profit from this nurse migration. Khadria (2007, p. 1433) describes this process in India as “business process outsourcing.” It includes a comprehensive training-cum-recruitment-cum placement for popular destinations like the United Kingdom (UK) and the US through a proliferating agency system. China and Korea are beginning to follow a similar path (Fang, 2007). The large population and growing tertiary education markets will facilitate this production of nurses for export.

Challenges and Current Solutions Related to Nurse Migration

In common with other types of educational expansion associated with the rise of globalization, the maintenance of nursing educational and subsequent practice standards is a continuous challenge. The shortage of experienced nursing faculty worldwide adds to the challenge of establishing and maintaining standards (Blythe & Baumann, 2008).

In an attempt to maintain standards, some countries have established stringent educational and regulatory requirements. Hence a nurse’s success in integrating into the workforce varies from country to country, depending partly on the educational investment that has been made by the nurse prior to migrating to another country. For example, if internationally educated nurses wish to practice in Canada beyond the time constraints of their temporary license, they must take the national licensing examination and fulfill the criteria for registration stipulated by the provincial regulatory body. Many nurses who migrate to Canada never reestablish their professional careers because they need substantial educational upgrading to be eligible to take the licensing examination (Baumann et al., 2006). Moreover, internationally educated nurses tend to have a relatively high failure rate in the national examination due to their unfamiliarity with the testing procedures and Canadian nursing (CNO, 2006). Nurses who migrate have to initially depend on their formative education in their home country to provide adequate preparation; and some pre-licensure nursing programs are more effective than others in preparing nurses to practice at the level required by the recipient country.

Most source and recipient countries have undertaken educational initiatives to ease the transition of migrant nurses. In recipient countries, colleges and universities have established upgrading or bridging programs to ensure that nurses are both competent to register and eligible for registration examinations. Recently, prior learning assessment and recognition (PLAR) initiatives have been undertaken in conjunction with or instead of other courses to provide practical validation of nursing competencies (College of Registered Nurses of British Columbia, 2006; Hendrickson & Nordstrom, 2007). Because there can be language and cultural adaptation issues, countries like the UK require foreign nurses to undergo orientation to the local culture of health care upon their arrival in the UK (Kingma, 2006; Nursing and Midwifery Council, 2005).

Another example of assistance to migrating nurses includes the services provided by the Commission on Graduates of Foreign Nursing Schools (CGFNS). This organization has a long history of assisting nurses who migrate to the US. It was established in “1977 at the encouragement of several government agencies and nursing organizations” (CGFNS, 2004, para. 5). The CGFNS “provides leadership in healthcare education, registration and licensure to the global nursing and healthcare community” (CGFNS, 2004, para. 5) and has introduced an International Council of Nurses-Affiliated International Centre on Nurse Migration (ICNM) (CGFNS, 2005; ICNM, 2005). The purpose of the centre is to establish “global and national migration policy and practice that facilitate safe patient care and positive practice environments for nurse migrants” (ICNM, 2005, para. 1).

...one way of ensuring quality is to test nurses’ competencies before they leave their country of origin. From the perspective of receiving countries, one way of ensuring quality is to test nurses’ competencies before they leave their country of origin. To assure that nurses are eligible for employment immediately upon entry to the country, the U.S.  National Council of State Boards of Nursing (NCSBN), the nurse examining body in the US, has set up examination centres in major cities around the world to test the competencies of nurses who desire to migrate before they leave their home country rather than after they arrive in their new country. It often works in partnership with local nursing associations, regulatory bodies, and educational institutions (NCSBN, 2006).

Other countries (e.g., Canada) also hold licensing examinations abroad. The Manitoba College of practical nurses has held several examinations for potential immigrants from the Philippines (Horizon Recruitment Pacific Corporation, n.d.), thus providing a degree of nursing practice screening before immigration. Other countries ensure a supply of foreign nurses by additional means. For example, the U.K. government has made agreements with governments in several countries where nurses are comparably educated to supply quotas of nurses for defined periods (Kingma, 2006), thus providing greater assurance of practice competency on the part of the nurses who enter the UK. Still other countries allow foreign nurses to practice in their jurisdictions for limited periods. Usually the criteria for allowing internationally educated nurses to practice for short periods are less stringent than for those that remain indefinitely. In Canada, temporary registration is granted for six months to internationally educated nurses with appropriate qualifications (College of Nurses of Ontario [CNO], 2008).

Current Standards and Harmonization in Transnational Nursing Education

A critical issue in transnational nursing education is the absence of a body that has international authority to monitor educational standards worldwide...A critical issue in transnational nursing education is the absence of a body that has international authority to monitor educational standards worldwide, even though some attempts have been made to establish international standards that reconcile standards with cultural diversity. There is also a lack of internationally sanctioned mechanisms for making comparisons among programs in different countries. The latter is particularly important because educational institutions that wish to be major international players need accreditation to attract students and to promote quality education.

There is, however, a strong history of accreditation within countries. Accreditations for professional programs are strong but are largely “in country.”  For example, the US and Canada have well established systems of voluntary accreditation in higher education (Eaton, 2006). National accrediting organizations assure common standards and expectations. These organizations are often called upon by other countries to send teams to adjudicate accreditation status for foreign programs. Examples of established nursing accreditation programs are the National League for Nursing Accrediting Commission (NLNAC) and the American Association of Colleges of Nursing (AACN) in the US; and the Canadian Association of University Schools of Nursing (CAUSN). The NLNAC accredits nursing programs of all levels, while the AACN accredits baccalaureate programs for nurses who will be entering nursing with a baccalaureate degree. It advocates the baccalaureate “as the minimum educational requirement for professional nursing practice” (AACN, 2000, para. 1).

There is...a lack of internationally sanctioned mechanisms for making comparisons among programs in different countries. The European Union has paid considerable attention to addressing the problem of reconciling cultural diversity with standards. In 2001, the Lisbon Recognition Convention Committee adopted a Code of Good Practice in the Provision of Transnational Education (Council of Europe, 2008). In a more direct attempt to reconcile diversity and standards, a component of the Bologna process, titled “Tuning Educational Structures in Europe,” has examined structures such as curricula. This document is intended to promote points of reference, convergence, and common understanding as the basis of curricula that would lead to the development of common key competencies, while protecting the rich diversity of European education (Marrow, 2006).

Additional attempts to establish standards for transnational education include the Guidelines on Quality Provision in Cross-Border Education prepared by the United Nations Educational, Scientific, and Cultural Organisation (UNESCO) and the Organisation for Economic Co-operation and Development (OECD) (Davies & Wong, 2006). The UNESCO website <www.unesco.org> provides information on post secondary systems worldwide and their quality assurance mechanisms. However, students who require acceptable credentials must themselves exercise great caution because there is always the potential for fraud or exploitation. The Council of Europe (2008) advises potential students to be extremely vigilant about spurious claims of endorsement in stating, “We wish to make it clear that the Council of Europe does not recognize or in any other way bestow legitimacy on any higher education institution, program or provision” (para. 2).

Trends and Future Directions in Harmonizing Nursing Education Internationally

In addition to differences in education, the nursing profession varies by country in how it is regulated. Nurses have existed in many cultures since ancient times (Sapountzi-Krepia, 2004). In Europe and North America, modern nursing developed in the mid 19th century and spread to much of the world through the globalizing mechanisms of warfare, colonialism, and missionary activities (Basuray, 1997; Nestell, 1998). The roots of nursing in the Middle East, however, can be traced even further back, to the Islamic Period (570-632 AD) and to Rufaida Al-Asalmiya, the first Muslim nurse (Miller-Rosser, Chapman, & Francis, 2000). From its foundation in 1899, the International Council of Nurses (ICN) has envisioned an international federation of national nursing organizations that would ensure high standards of nursing education and practice globally. Its founders reasoned that principles governing nursing education and practice should be the same in every country (ICN, n.d.).

Unfortunately in the early 20th century, as nursing established itself as a profession, globalization waned. Two world wars and the Cold War meant that the profession diversified. This resulted in a great deal of variation in the way nurses were educated. For example, until recent years, all nursing education in the Soviet Union and the Eastern Bloc occurred exclusively at the secondary school level and was subordinate to medicine (Jones, 1997). In other countries, professional education was increasingly taught at the tertiary level, but curricula content and program length varied.

Although the ideal of worldwide standards for nurses promoted by the ICN for over a century remains unrealized, the forces of globalization have created an impetus for change. In addition to differences in education, the nursing profession varies by country in how it is regulated. In a number of countries, to protect the public, regulated professions have designated standards for their members and reinforced these standards by withholding registration from individuals lacking appropriate educational or other credentials (ICN/World Health Organization [WHO], 2005). In other countries, regulation has taken a variety of forms; and in some countries, nursing has not yet become an autonomous, regulated profession. Differences in regulatory criteria are barriers to internationalization. Where regulation occurs at the regional or provincial level, mobility within a country is an issue (WHO/Sigma Theta Tau Honor Society of Nursing [STTI], 2007).  Yet data collected from the Organization for Economic Cooperation and Development’s (OECD’s) 30 member countries (listed in the Table) shows that about 11% of nurses in these countries are foreign educated (2007). This high proportion of foreign nurses indicates that a measure of accommodation exists among the divergent systems of education and regulation allowing nurses to practice outside their countries of origin.

Although the ideal of worldwide standards for nurses promoted by the ICN for over a century remains unrealized, the forces of globalization have created an impetus for change. Education of health professionals, specifically nurses, cannot be entirely homogenous given population health issues, such as endemic diseases, along with social, cultural, and economic differences. However, standards for nursing education need to be established throughout the world to provide a guide for local services and to assure a minimum standard for important issues such as essential qualifications for nurse educators. There have been several initiatives to identify and address barriers to achieving global standards.

Education of health professionals...cannot be entirely homogenous given population health issues, such as endemic diseases,...social, cultural, and economic differences. Among the projects focusing on quality of nursing education is the recently formed Joint Task Force on Creating a Global Nursing Education Community. This initiative is designed to share information and promote quality standards. A meeting led by WHO and STTI was held in Bangkok, Thailand, in December 2006. The goal was to initiate the development of global standards for basic nursing and midwifery education and to address patient safety and quality of care issues that result from the large-scale migration of healthcare providers. Major themes included the development of global standards for program admission criteria, program development requirements, program content components, faculty qualifications, and program graduate characteristics (WHO/STTI, 2007). Further work in this area is important and necessary.

Aspects of globalization such as professional mobility, health sector reform, and public concern with the quality of healthcare services have led to greater interest in nursing regulation. In conjunction with WHO, the ICN has established a regulation network as both a forum for exchanging ideas, experience, and expertise in regulatory issues affecting nursing and also as a source of information and guidance to deal with emerging issues (ICN, n.d.). Conferences are held at regular intervals, with the most recent, as of this writing, held in Geneva in May, 2008 (World Health Professions Alliance, 2008).

While international and national nursing bodies are focusing on international standards for nurses, more inclusive movements for educational harmonization that involve national governments are under way. One of the most significant is the Bologna process or Bologna accords.  The purpose of this undertaking is to make academic degree standards and quality assurance standards more comparable and compatible throughout Europe. The process extends beyond the EU to include some 45 countries (Zgaga, 2006).

Academic records or diploma titles enable European Union nurses to register and work in any EU country. Clearly, further harmonization is required. Academic records or diploma titles enable European Union (EU) nurses to register and work in any EU country. Currently, nursing programs that enable nurses to practice in the EU have been subjected to two European directives regarding the qualifications of “nurses responsible for general care.” Directives 77/453/ECC and 89/595/EEC stipulate that a “registration program should be at least 3 years long or 4,600 hours” (Zabalegui et al., 2006, p. 115). However, a survey of nursing education in the EU indicates programs take place in a variety of universities, colleges, and schools and that curricular and degree structures vary greatly (National Nursing Research Unit, 2007). Despite these differences, entrance examinations are not required when nurses migrate.

The Bologna process offers the opportunity to standardize nursing education, with the bachelor’s degree as the entry level to the profession, and master’s and doctoral degrees recognized in all EU countries (Zabalegui et al., 2006). Some European countries have already adopted a three-year bachelor’s degree as the criterion for entry to practice. Other countries, including some in Eastern Europe, are moving toward this standard (Krzeminska, Belcher, & Hart, 2005; Marrow, 2006).

The Tuning Educational Structures in Europe project, a component of the Bologna process, builds on previous endeavours to enhance inter-university cooperation and aims to identify generic and specific competencies for nursing graduates at bachelor’s, master’s, and doctoral levels (for additional information on these specific competencies see Gobbi, 2004). Graduates, academic faculty, and employers participated in the project, which included a method designed to make the different nursing curricula understandable across countries. The process used by these team members led to the identification of 30 generic and 40 specific nursing competences that will serve as a framework for evaluation. Zabalegui et al. (2006, p. 117) noted that “within this new structure, a bachelor in nursing or nursing science will denote achievement of the specified competencies in an academic environment.”

While the Bologna process directly concerns Europe and its immediate neighbors, it has generated global attention because harmonization of nursing in this large geographical area will have worldwide repercussions (Zabalegui et al., 2006). It has aroused the interest of countries such as Australia and New Zealand, rival providers of educational services (Australian Department of Education, Science and Training, 2006; New Zealand, Ministry of Education 2007), as well as countries in the Far East (Zgaga, 2006).

Schools of nursing in the Philippines, India, and China will need to take the stipulations of the Bologna process and the competencies identified in the Tuning project into account if they wish their graduates to be eligible to work in Europe. Other economic and political partnerships elsewhere in the world may be interested in participating or developing their own harmonization projects. While educators in North America may prefer alternative approaches to nursing education, they will need to address educational equivalences and differences in nursing education and nursing qualifications. Careful comparisons between education systems may be necessary. For example, competencies and hours of instruction or clinical practice may need to be considered when calculating equivalencies.

Conclusion

Organizations such as the ICN and WHO Collaborating Centres for Nursing, which work in partnership with existing strong accrediting bodies, are suitable, overarching global organizations to provide the thrust for creating these international educational standards. Globalization has created a world market that favours mobility. For workers to take advantage of new opportunities and for employers to attract workers, mechanisms are needed compare the education and qualifications of applicants against global standards. Because nations have specific requirements related to technology and disease prevalence, as well as cultural, social, and environmental differences, it is unlikely that education will ever be uniform. However, it should be possible to determine common competencies and skills upon which assessment could be based. There still remains the lack of a comprehensive framework to address the diversity and unevenness in the quality assurance processes of cross-border higher education. The challenge is to develop appropriate procedures and systems to cover foreign providers and educational programs in-order-to maximize the benefits and limit the potential drawbacks of internationalization of higher education. This is especially important in healthcare given the mandate for medical and nursing interventions in direct patient care in complex health systems.

The overall goal of any human resource plan is a continuous, predictable workforce, a supply of workers from reputable educational programs, and a system in place that recognizes cross-cultural differences. The argument is not for homogeneity; rather, it is for predictability and competence. International nursing accreditation standards would provide the blueprint and direction for schools of nursing. At present, there are some quality review systems in place; these prototypes need to be expanded. Cross-country agreements like the Bologna process are a positive step, but attention still needs to be focused on the education of health professionals, specifically nurses, to assure consistent and high quality standards. Organizations such as the ICN and WHO Collaborating Centres for Nursing, which work in partnership with existing strong accrediting bodies, are suitable, overarching global organizations to provide the thrust for creating these international educational standards.

Authors

Andrea Baumann, PhD, RN
E-mail: baumanna@mcmaster.ca

Andrea Baumann is the Associate Vice-President, Faculty of Health Sciences, (International Health), McMaster University and the Director of the Nursing Health Services Research Unit (McMaster site). She is the Director of the World Health Collaborating Centre in Nursing Human Resources. Her research interests include clinical decision making, human health resources, and international health. Her recent publications include Safe Staffing Saves Lives and Positive Practice Environments: Quality Workplaces = Quality Patient Care. Both are Information and Action Tool Kits developed for the International Council of Nurses. In addition to her research, she has directed several international projects in relation to capacity building and higher education for women.

Jennifer Blythe, MLS, PhD
E-mail:  blytheje@mcmaster.ca

Jennifer Blythe is an Associate Professor in the School of Nursing at McMaster University and Senior Scientist in the Nursing Health Services Research Unit (McMaster site), funded by the Ontario Ministry of Health and Long-Term Care. The unit is multidisciplinary and focuses on health human resources and health services. Dr. Blythe’s research interests include health human resources and nurse migration, both of which encouraged her to contribute to this article. She is one of the authors of a recent government report that addresses the integration of internationally trained nurses into the Canadian workforce.

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