Doctoral Nursing Education in Europe
Academic education in nursing in Europe at the university level was first established in the UK in 1950s (Hamrin, 1997; McKenna and Cutcliffe, 2001). Today, academic nursing education is the norm in most of the member states of the EU, and much progress is ongoing. In Finland (Leino- Kilpi and Uski , 2001), programs for doctoral degrees exist in five universities: Kuopio, Oulu, Tampere, Turku and Abo Akademi (in Swedish). In these universities, most of the faculty are PhD-prepared.
In the 1990s, there was an increase in the numbers of nurses holding doctoral degrees in many countries. In 1992, there were about 160 nurses with doctorates in Sweden, 40 in Finland, 13 in Denmark, 20 in Norway and 7–8 in Iceland (Hamrin, 1997). In Finland, the number of doctorates has been rapidly increasing. The first doctoral graduation took place in 1984, and today, there are close to 200 doctorally prepared nurses.
Between 1997 and 2002 there were 118 graduates and numbers are increasing: in 1997, there were 11 PhD-graduates from the five universities and in 2001 the corresponding number was 24. The same growth trend is seen in other disciplines in Finland (Academy of Finland , 2003). Despite these advances, there are relatively small numbers of doctorally prepared nurses in the European region.
The type of doctorate available for nurses is usually the PhD, as is the case in other Nordic countries. There are two ways to conduct doctoral study (Hamrin, 1997; Rahm-Hallberg, 2003): as a monograph prepared at the end of doctoral studies or as a composite dissertation including internationally published papers and a summary.
The latter has a stronger tradition in the universities where academic nursing education takes place in the medical faculties, as is the case with three Finnish universities (Oulu, Tampere and Turku). The doctoral student chooses the way to present the study, but it also depends on the topic: there are more international opportunities to publish in clinical fields, than, for example, in nursing education. Also, the selection is dependent on the linguistic skills of the doctoral students.
The field of study for doctoral students depends on the research program of the university. In Finland, clinically oriented dissertations are most common, KNOWLEDGE DEVELOPMENT AND DOCTORAL EDUCATION IN NURSING 31 followed by those in nursing education and administration. This seems to be the common trend in the other Nordic countries, too. Research programs in universities are more or less homogeneous, and the content is dependent on the health and nursing priorities in the country.
One of the main problems in many countries is that there are too few nursing professors and other senior researchers for the supervision of doctoral students. Senior researchers, thus, have more than one area to study but even then many important fields of nursing remain without any funded research projects.
In Finland, the Ministry of Education established the graduate school system in 1995. Within the next few years the Government of Finland made the important decision to increase public funding for this system. In nursing science, there is also a National Doctoral School with ten enrolled doctoral students who are also employed. This national school is working in collaboration with the five universities.
The universities organize four to five national doctoral courses together annually, invite international researchers and support the networking of doctoral students. Based on the report of the Ministry of Education (2000), there has been a gradual decrease in the number of years to completion of the doctoral dissertation, and about 60% of students completed their doctoral studies within the prescribed four years of study.
The mean age of nursing science PhD students (40 years) is high compared with other disciplines (median for all disciplines was 36 years in 1999), but there is a decreasing trend at the National Doctoral School. Graduation at a later age means less time to establish a research career and this, in turn, inhibits the systematic development of knowledge in the field.
Influence of Demographic, Social and Political Factors, and Health Priorities on Nursing Research and Doctoral Education
Ageing Population
In 1999, the population of the EU was about 375 million people. A main demographic factor influencing the need for doctoral nursing education is the aging of the population. Aging means an increasing proportion of elderly people in the population and, individually, it means increasing life expectancy.
According to the OECD Health Data (www.oecd.fr; accessed 15.8.2003) in Finland, for example, life expectancy has increased by about 10 years since the 1960s and the trend is similar in most of the member states of EU (www .europa.eu.int/comm/ eurostat ; accessed 17.8.2003; In 1990, the average of the old-age dependency ratio (ratio of older people to people in traditional working age) in the OECD countries was 19% (Hicks, 1996). By 2030, this could nearly double to 37%. The growth will be particularly rapid after 2010 in the population over 80 years of age.
Aging is an individual process. It means that the number of people of retirement age is growing and they need more health services. This situation has financial ramifications, and requires new patterns of care-giving to families. The elderly population is also living rather well: based on the study among nine OECD countries (OECD, 2001) older people at all income levels tend to maintain their material standards of living once they stop working.
This happens despite differences in approaches to public policy, such as pensions. Nurses take care of elderly people in their homes, communities, primary healthcare settings, hospitals, long-term institutions and nursing homes. In nursing education, there are programs for elderly nursing, and this is one of the main foci of nursing research. In Finland, the Academy of Finland has funded a large national multidisciplinary research program in aging and development of health services for the elderly population.
Nurse researchers have developed theories for nursing care of elderly people in homes and long-term facilities. In these research groups, doctoral students have a major role. A need for a nationwide nursing research project in elderly nursing care, in which doctoral students could be immersed and mentored, has been identified as a priority for the future.
Health Priorities
Health priorities are dependent on many factors. Current available data do not allow the systematic measurement of health status in a way that does justice to the concept by including measures of quality of life—a concept more close to nursing. Statistics usually look at causes of death, morbidity, and disability. In Finland, for example, the main causes of death are cardiovascular diseases, cancer, pneumonia and other infections, cerebrovascular diseases and accidents.
Infant mortality is one of the lowest in the world (OECD, 2003). These data are very similar in Nordic countries (European Commission, 2003): cardiovascular disease is the main cause of death in women in all countries of Europe and is the main cause of death in men in all countries except France. In Europe, women (15 years and older) enjoy a high level of health as measured by a variety of health indicators.
Life expectancy has increased, maternal mortality is low, women perceive themselves as healthy and have been getting workshop. In spite of this generally good health status, there are problems with disability, activity limitations, mental disorders and accidents. Special issues in women’s health are eating disorders, human immunodeficiency virus/acquired immune deficiency syndrome, osteoporosis, as well as violence against women.
The vast majority of young people in Europe enjoy good health (European Commission, 2000). There are, however, also many specific health issues. Among these are inequalities in young people’s health between families, population subgroups and countries, substance abuse and mental disorders. InFinland , for example, within the past few years, more resources in healthcare have been geared to mental health of children and adolescents.
Globally, the major health risks have been analyzed by the WHO. This analysis points out risks as follows: childhood and maternal under-nutrition, diet-related risks, physical inactivity, sexual and reproductive health, addictive substances, environmental risks and occupational risks. Only some of these issues are relevant to Finland, Nordic countries or Europe.
For example, physical inactivity is a risk for many health problems, such as cardiovascular diseases, high blood pressure and overweight. Risk factors in the area of sexual and reproductive health can affect well-being in a number of ways. The largest risk by far is that posed by unsafe sex leading to infection with HIV/AIDS. The numbers of these infections are still low in Finland and Nordic countries, but they are increasing.
Also, the same increasing trend can be identified for addictive substances (OECD, 2003). Environmental and occupational risks are partly related to each other. In the Nordic countries, these are manifested in environmental problems in urban areas, as work-related carcinogens, and ergonomic and psychological stressors.
What does the analysis of health risks mean to doctoral education in nursing? It means that nursing research needs to respond to these health issues and risk factors in many countries, if not globally. However, there is not much research collaboration globally, or between the major world regions. There are, however, numerous international research projects within Europe, between and among European, US and Canadian universities; More recently, research collaboration has included researchers from Australia, Japan and Taiwan as well.
These efforts should be fostered in the future. The health risks described mean that there is still a need for nursing research in the areas of prevention, health education, healthy ways of living, health impact assessments and evaluation of the outcomes of health promotion. In the Nordic countries, there is an emphasis on health promotion in health policies, maternity care, care of children and school healthcare.
In spite of this emphasis, however, there is a need for evaluation of health promotion. It is especially the case that cardiovascular and long-term diseases require research. It is critical therefore that doctoral students learn to analyze the health risks, and be able to use the information included in the health statistics in their projects.
Social and Economic Factors
The major determinants of health problems are behavioral (eg smoking, lack of physical activity, drug addiction), poor environmental conditions and low socio-economic status (European Commission, 2003 www.who.int; accessed 19. 8.2003). The vast majority of threats to health are more commonly found among poor people, people with little formal education, and those with lowly occupations. One in eight people lived in a jobless household in the EU in 1999, but there are major differences between the countries (Eurostat, 2003a, 2003b).
Looking at the monetary indicators, at-risk-of-poverty rate is highest in Portugal and Greece, and lowest in Sweden, Finland, the Netherlands, Denmark and Germany.
onomic factors include, among others, the total expenditure on health in the country (% gross domestic product (GPD), OECD, 2003). In Finland, this has increased from 5.6% in 1970s to 7% in 2001. The corresponding percentages in the USA are higher: 6.9% and 13.9% respectively. Per capita expenditure in 2001 for Finland was US$1841, and for the USA US$4887. The variation, of course, reflects the differences in healthcare systems. It also informs us on how health is valued in the social policy of the country.
Economic factors can be identified both at a macro level (eg GPD per capita) and at an individual micro level, and they depend on the system of social security and healthcare policy in the countries. In the Nordic countries, earnings are most equitably distributed, individual living standards are good and the level of education is high.
The greatest inequalities in Europe seem to occur in Spain and the UK (European Commission, 2003). Nursing research has focused on individual poverty rather than community level political decisions in resource allocation. In future, both of these levels should receive attention in nursing research. This is a useful field for multidisciplinary research projects.
Women’s lives have changed in Europe during the past three decades (www.europa.eu.int/comm/health; accessed 30.7.2003). The rate of marriage has declined and the average age at first marriage (26.1 years) and at first birth (28.6 years) have risen. Women’s participation in the labor force has increased (there are variations across Europe). The Nordic countries have the highest rates of gender equality, in part because of higher levels of education and income relative to men.
Nursing research is concerned with families, communities and their healthcare. Traditionally, the family represents the first source of informal healthcare and the best support system for the young and the old. Thus, family structures are important sources of companionship and are associated with patterns of mental health, as well as other health problems. This means that all areas of family nursing are of great importance for doctoral study, and this is further emphasized because of aging populations and shorter lengths of hospitalization.
Healthcare Organization
Healthcare organization, healthcare personnel and the needs of nursing workforce are also related to doctoral nursing education. 1998 estimates of health personnel in European countries vary among nurses: In Greece there are 257 nurses/100,000 population; the corresponding number in Finland is 2162 and in the USA 972 (www.who.int; accessed 19.8.2003). Adding to this, the nursing workforce profile (ICN, 2003) gives interesting information.
For example, the average age of employed nurses varies between 30 years in Germany and 44.7 years in Sweden; in USA it is 43.3 years. This means that there will be many retirements in the future. The employment status also varies. In Iceland, for example, nurses employed full time (35 hours or more/week) comprise 25% of the total nursing population, with 43% in Norway, 49% in Denmark, 55% in Sweden and 72% in the USA.
The healthcare systems in the Nordic countries have many similarities. For example, the main employer in the Nordic countries is the public sector. Since the 1990s, there have been many changes in the healthcare organizations. These have to do with acute care: number of beds and average length of stay in hospital have decreased (OECD, 2003).
Finland illustrates this change: in the 1960s the average length of stay in acute care was 12.5 days, in 2001 it dropped to 4.4 days. In the USA, it was 7.6 days in the 1960s and 5.8 days now, which does not indicate as large a change as in the Nordic countries. In many countries, the challenges for their healthcare systems are similar.
The European Observatory on Health Care Systems (2002) conducted an analysis of eight countries in Europe including Denmark, France, Germany, the Netherlands, Sweden and the UK. Major challenges in these countries had to do with cost management, aging, quality programs, limited resources, long waiting lists for patients, shortage of medical and nursing staff, issues in public healthcare and community, and also questions about the realization of patients’ rights .
For nurse researchers, changes in organization are also a challenge. Nurses’ roles, particularly in nursing-sensitive outcomes, are of great importance. Also, the role of patients has changed: the shorter stay in hospitals and increasing numbers of day-surgeries, increasing nursing responsibility for teaching and supervising patients, and increasing need for home care nursing and community support. In the nursing knowledge base, empowerment of patients is important. We still do not know enough about the empowering process and the role of nurses in that process.
Patients’ rights are part of the ethical knowledge base in nursing. Rights include, for example, the right to access medical treatment and nursing care, the right to information and the right to high level, professional care. In Finland, these are defined in the Act on Patients’ Status and Rights (No 785/1992, www.finlex.fi; accessed 15.7.2003). To date, ethics has not been in the mainstream of nursing research.
The situation changed somewhat in Europe in the 1990s, because of the research funding by the European Commission. For example, funding has been provided for nursing research in the areas of autonomy, privacy, and informed consent of patients in elderly care, postnatal and surgical nursing (eg Leino- Kilpi et al, 2000) and for research in ethical codes in nursing ( www.ecn.nl; accessed 15.7.2003). Doctoral students from many European countries have been involved in these initiatives.
Information and communication technologies are economic factors in healthcare organization. Investment in information and communication technology has been the most dynamic component in recent years (OECD, 2002), technology has been developed in hospitals, primary healthcare and for improving communication between people’s homes and the healthcare organization.
Communications equipment was the most important area for investment in 2000 in Finland; the highly skilled information and communication technology workers had an annual growth rate of about 49% during 1997–1999. This means that new technology has been invested in nursing as well, giving rise to the need to study the outcomes of such technology.
Doctoral students in nursing science are mostly experienced nurses within the Nordic countries. Experience supports understanding of issues in healthcare organization from different perspectives. Experience also produces relevant research questions about healthcare organizations and understanding to formulate projects in that field. In summary, evaluation of healthcare organization is deemed an appropriate area for research for doctoral students in nursing.
Future Challenges for Doctoral Education in Europe
Despite the growth described earlier, there are still a limited number of doctorly prepared nurses in Europe. On the one hand there are still countries without any academic nursing education and on the other there are many countries with high level academic education and research—and there is increasing collaboration between countries. Inside the EU, for example, the Socrates and Erasmus exchange programs have provided opportunities for doctoral nursing students to create international networks.
Collaboration also takes place through the European Academy for Nursing (EANS, www.eans.org; accessed 20.7.2003), the Nordic Academy for Advanced Study ( Norfa ) and different agreements between European universities. The Nordic countriessupport nurse researchers in the Baltic countries. Also, in many countries there is national collaboration between universities.
In addition, more funding is available through the European Commission, new scientific journals have been established, and the numbers of presentations at conferences and publications have increased. All these developments enhance new ideas for knowledge development and doctoral education. There are many challenges in knowledge development and doctoral education in nursing for the future.
1: Nursing research should reflect the health problems in the country or relevant region. This requires doctoral students to analyze the health issues in their country and produce relevant knowledge for supporting nurses working with clients. Based on the health statistics, in Europe there is a need to study, in particular, patients with cardiac diseases, cancer and chronic illnesses (Jonsdottir, 2001), as well as issues connected with healthy ways of living and health promotion.
There is also a need to study mental health problems, problems caused by changes in health organization, family nursing issues (Tomlinson and Hall, 2003) and disease prevention. The ethical knowledge base should be strengthened.
2: The need for evidence-based nursing is recommended for doctoral students. This challenge is mainly methodological: they need to be educated in experimental designs.
3: Doctoral students need to be educated in the field of health problems of aging populations. Health issues today are more complicated because of the aging population and new technologies in medicine. To be able to approach these issues, doctoral students in nursing need to work and learn in multidisciplinary research teams. Such teams should include medical and other health science students (Rahm-Hallberg, 2003).
4: Universities need to have an active interchange with the community; In nursing this means active collaboration between researchers, doctoral students and nurses in practice. In Finland this has been supported by establishing a cross-appointment position for professors between universities and university hospitals in each of the five universities.
5: Nursing research is not only concerned with health issues and supporting nursing problems in practice. Doctoral students need to participate in theory construction, instrument development and philosophical analysis of science. Without this, nursing does not meet the requirements of an academic discipline.
6: International collaboration between nurse researchers is a fact today, at least in many European countries. International collaboration often means empirical data collection in more than one country. Data collection implies different research ethical issues and learning experiences, as indicated by the Working Group for the Study of Ethical Issues in International Nursing Research (2003).
7: There is a need to study the outcomes of health information and communication technologies, both in hospitals and communities. By using technology effectively, some problems of nursing shortages could be solved.
8: A very limited number of universities offer postdoctoral education. Researchers are encouraged to find colleagues interested in the same health and nursing issues to work with. Presently, it seems to be relatively easy for doctoral students to find international partners. This is the case particularly among those students who make a composite dissertation and publish papers from their studies during doctoral education.