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Undergraduate nursing education reform in France: from vocational to academic programmes inr_1016

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C. Debout3 RN, CRNA, MSN, MPHIL, PhD, F. Chevallier-Darchen2 RN, MSED, O. Petit dit Dariel1 RN; MSN, PhD & M. Rothan-Tondeur4 RN, ICPO, PhD 1 Professor, 2 Research Assistant, 3 Head of the Department, 4 AP-HP/EHESP Nursing Research Chair, Department of Nursing and Allied Health Professions Sciences, Ecole des Hautes Etudes en Santé Publique, Rennes Sorbonne Paris Cité, France

DEBOUT C., CHEVALLIER-DARCHEN F., PETIT DIT DARIEL O. & ROTHAN-TONDEUR M. (2012) Undergraduate nursing education reform in France: from vocational to academic programmes. International Nursing Review 59, 519–524 Background: France is currently implementing a number of reforms to the healthcare and education systems. Within this context, a comprehensive reform of undergraduate nurse education was launched in 2009, bringing nurse education closer to the higher education environment. It is likely in future to move from being vocational towards becoming an academic educational programme. Aim: In this paper, the 2009 reform of the French pre-registration nursing curriculum will be analysed in light of the European framework. Process: The pedagogical approach, methods and content of nursing education in France are undergoing an in-depth reorganization. The main innovation that the reforms introduce is a competency-based approach. France is joining the group of countries that require first degree-level entry to the nursing profession. Conclusion: There are still many unanswered questions regarding the competencies and qualifications required by both the academic and clinical educators many of whom have not been previously involved in research or publications. The future status of nursing science is unclear, as is the way in which the nursing profession will be able to retain control over its educational mechanisms. Keywords: Nursing, Reform, Undergraduate Education

Introduction Education has been recognized as an essential means of promoting the quality of care provided to patients ever since modern nursing developed in the last part of the 19th century. Education has also played a crucial role in the professionalization process in which nurses have engaged in order to be recognized as a unique Correspondence address: Dr Christophe Debout, DSIP-ORIG, Hôpital Charles Foix, 7 Avenue de la République, 94205 Ivry sur Seine Cedex, France; Tel: 33-0-1-49-59-42-19; Fax: 33-0-1-49-59-49-94; E-mail: [email protected].

No conflicts of interest have been declared by the authors.

profession. According to Holland (1999) and Wynd (2003), education is one of the most important factors differentiating occupations. A profession thus has the responsibility to educate its practitioners bringing them the specific knowledge they need to practise and to produce new knowledge through research (Emerson & Records 2005). Practising professional education in higher education contexts and keeping control over education have also been identified as two major characteristics of a profession. This professionalization process began early in the history of nursing (Knibiehler 1984). Supranational organizational support was helpful during this process (Magnon 2001). In

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France, nursing is currently still struggling to further this process. The profession has been regulated since 1922 and the diploma is required to work as a nurse since 1946 (DuboysFresney & Perrin 1996). An autonomous nursing role was recognized by French law in 1978 (French Ministry of Health 1978). More recently, professional self regulation was introduced in 2006 (French Ministry of Health 2006). Despite the introduction of modern nursing in France, education continues to remain ‘vocational’. Nursing schools are located outside of higher education resulting in very low research capacity in the production of nursing knowledge. In 2009, French nursing reached a turning point: the pre-registration curriculum was profoundly reformed (Ministère de la Santé 2009a). A bachelor degree level is now the entry level in nursing in France thus aligning itself with other European countries. Education replaces training. To achieve this goal, nursing schools must now collaborate with higher education institutions (HEI) to build the competencies their students need to practise their profession.

The European Union (EU): its role in nurses’ education Nursing, as a regulated profession serving the public, has been the focus of a number of European policies. The characteristics of the European professional nurse have been determined and educational requirements have been established for years. More recently due to the integration of nursing programmes in the higher education system in a growing number of European countries, nursing education has experienced profound reforms following the Bologna Declaration. French nursing organizations lobbied actively to obtain from the government the academization of the nursing education system. A closer look at the impact the EU has had on nursing education can shed some light on the current situation. One of the major goals of the Treaty of Rome was to provide free movement for the citizens of the EU. Achieving this goal was not an easy task and required the development of complex mechanisms to facilitate mutual acceptance of education and qualifications acquired across all the EU countries. Regarding nursing and more specifically pre-registration nursing education, sectoral directives 77/452/EEC and 77/453/EEC were adopted in 1977 to harmonize the programmes across EU (Council of Europe 1977a,b). Content, number of hours and the length of pre-registration programmes were specified. General system directives were also used to facilitate the recognition of certain post-qualification specializations in nursing. In 2005, these directives were replaced by the Directive on the Recognition of Professional Qualifications within the EU (2005/ 36/EC, European Parliament 2005) to simplify the process of mutual recognition. A set of requirements was adopted regard-

ing the curriculum for the generalist nurse: entry into a nurse education programme would require a minimum of at least 10 years of schooling; the programme would be delivered on a full-time basis; and at least last 3 years or including a minimum of 4600 h of theoretical and clinical training. Clinical placements were identified as an essential component of the curriculum and the content of the curriculum was also delineated. Theoretical instruction would include nursing, basic sciences and social sciences while clinical placements would cover medicine, surgery, paediatrics, home-care nursing, mental health and psychiatry. It was intended that these supranational directives would allow for the mobility of general nurses within the EU and protect the EU’s population. Moreover, in the Munich Declaration, the World Health Organization (WHO) urged all European governments ‘to strengthen nursing and midwifery by improving initial education and access to higher education’ (WHO 2000). This statement was published at a time when higher education in EU was involved in a ‘quiet revolution’ (Davies 2008) as they implemented the objectives of the Bologna Declaration adopted in 1999. The Bologna Declaration aimed to make European Higher Education more compatible and comparable but also more competitive and attractive. The main features of this project were to adopt an easy to read system of academic degrees based on two cycles (first cycle: undergraduate; second cycle: master’s and doctoral degrees); to establish the European Credit Transfer System (ECTS); and to promote the mobility of students and faculties.

Nurse education in France before the reform The model developed in France to reform nursing in the last part of the 19th century was introduced as a means of achieving two goals: to help physicians develop clinical and scientific medicine and to secularize hospitals. As such, a republican nursing model was developed by physicians and the modern nurse was perceived as the handmaiden to the medical profession, trained to be the eyes and hands of the physician during his absence. The first formal training programme in France was developed in 1878 in Paris by the physician Dr Bourneville. No prior education was required prior to entry into this programme and the content of the curriculum included some medical knowledge with a heavy weighting on morality. Apprenticeship during this period was considered a key part of nurse training. Since then, both nursing as a profession and nursing education have followed a slow process towards achieving greater autonomy from this medical stronghold. The WHO and EU position statements about nursing were used as powerful levers at the national level. Pre-registration nursing programmes have been periodically reformed as a consequence of the changing needs of the population and the organization of the health system. Until 2009,

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nurses were only educated at diploma level and the content and the accreditation of nursing schools were the preserve of the Ministry of Health (MoH). Nursing licensure and diploma were obtained simultaneously following the completion of an accredited nursing programme. Since the 1977 directive, programmes have been aligned with EU directives. The number of student nurses admitted to nursing programmes is still subject to national quotas implemented since 1979 to bring the nursing workforce in line with the needs of the health system (e.g. in 2009, 30 514 nursing student positions were available). France has more than 300 Schools of Nursing (Barlet & Cavillon 2010), most of them attached to public hospitals and financed by regional authorities. In public nursing schools, except for the modest registration fees, education is free of charge for all the students. Nurse educators are responsible for implementing the national programme and have full autonomy in fulfilling this mission.

The 2009 reform of pre-registration nurse education There are number of factors that led to the recent 2009 nursing education reforms. Undoubtedly, it was a response to the evolving health needs of the French population. The implementation of major reforms to the organization of the French Health Service (Ministère de la Santé 2009b) together with the transposition of the Bologna Declaration in French Higher Education was also influencing factors. The reform of the pre-registration programme was preceded by the validation of a nursing competency framework. This competency framework resulted from working groups that included all the relevant stakeholders (professional bodies, trades unions, employers, other health professions, etc.) brought together to establish a descriptive list of activities that were developed and validated as competencies. The 2009 nursing competencies framework outlines ten competencies, five of which are core nursing competencies: (1) assess a clinical situation and establish a nursing care diagnosis, (2) design and implement a nursing care plan, (3) support someone in carrying out daily care, (4) implement diagnostic and therapeutic actions, (5) initiate and implement educational and preventative care. The others are designated as cross-cutting in that they are shared with other professions: (6) communicate and develop a caring relationship, (7) analyse the quality of care and improve professional practice, (8) research and employ professional and scientific data, (9) organize and coordinate care interventions, (10) inform and train professionals and trainees. This framework has served as a basis for developing the national nursing curriculum. The 2009 reform of the pre-registration nursing curriculum marked a major turning point in nurse education and intro-

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Fig. 1 The formal partnership established between HEI and schools of nursing.

duced significant changes in the education of French nurses. The professionalizing aim of education is now expressed in terms of competencies. Collaboration is currently taking place between schools of nursing and HEIs. Course content and pedagogical methods have been amended and responsibilities for student support while on placement have been reallocated. Some of the most significant changes that have occurred as a result of the 2009 reforms are discussed below. Pre-registration nursing education is now the realm of both the MoH and Ministry for Higher Education and Research (MoHER)

The MoH remains the certifier of the nursing diploma and the curriculum remains national. But pre-registration nurse education is now out of the exclusive realm of MoH as the MoHER awards a degree to students at the completion of their programme as well. The 120 ECTS credits obtained at the end of theoretical education are added to the 60 ECTS credits obtained during clinical placements to achieve the 180 ECTS credits required for bachelor degree-level equivalence. This new provision has required schools of nursing to establish formal partnerships with HEIs at the regional level (Fig. 1). In each region, schools of nursing must sign a formal agreement with an HEI (school of medicine) setting out: • the participation of the university representatives in educational council of the nursing school, and • the HEIs input into the teaching and exam panels. It has been determined that 27% of the curriculum be taught by university faculty. The great majority of these university faculties do not have a nursing background. The implementation of the curriculum will be evaluated regularly by the French Quality Assurance Agency for Higher Education (Agence d’Evaluation la Recherche et de l’Enseignement Supérieur – AERES).

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Problem-based learning as a central method

The use of problem-based learning has replaced the previous emphasis on key body systems and medical pathologies. Students work collaboratively to seek solutions to problems. They need to understand and formulate the problem and to determine what knowledge and data they need to solve the problem through the appropriate selection of interventions. The student nurse undergoes a three-stage learning process: understanding, action and transferring these skills to similar situations. Assessment Fig. 2 Theoretical content of the programme: four topics.

General structure of the programme

Undergraduate nursing education now spans three university years (it was previously 36 months) each semester lasting 20 weeks. The 2100 h of theoretical education include four major topics (Fig. 2): (1) nursing sciences and nursing techniques, (2) human sciences and law, (3) biology and medical sciences, (4) work methodology, English and information technologies. The teaching modules are split into two categories: • nursing science and nursing techniques that provide the constituent knowledge base for nursing competencies, and • biology, medical sciences and human sciences that are considered to contribute to nursing practice. These theoretical contents are taught using various pedagogical methods: lectures, directed study and guided personal study. The student nurse’s individual work is evaluated at 900 h: additional readings and assignment preparation. Theoretical education must be balanced against clinical placements. Nursing students must complete 2100 h of clinical placements. Vacations (11 weeks per year), directed studies and attendance during clinical placements are compulsory. The total amount of educational activity is 5100 h exceeding the EU requirement. A competency-based approach

The adoption of a competency-based approach is the most notable aspect of these reforms. The programme gives the student nurse the knowledge and know-how to gain the required competencies needed for practice. The teaching modules, the practical modules and the methodological modules are based on this pedagogical aim. Written assignment or skilful implementation of a nursing intervention in a clinical laboratory is not sufficient to validate a competency. To validate a competency, the student must pass assignments exploring their knowledge acquisition but they also need to demonstrate that they are competent to perform nursing interventions at the patient bedside.

There is a variety of evaluation methods. Evaluation can be individual or collective, ongoing or exam based. An assignment format is proposed for each module. Students have to pass many assessments throughout the programme. They also need to write a research project focused on a professional topic and to defend it. A student’s progression through the programme is conditional on total or partial validation of each semester with organized remedial sessions. It is possible to repeat a year, up to a maximum of six registrations during the whole course period. Placements and mentorship

Student nurses must undertake seven placements in four different types of healthcare settings: • acute care (hospital), • mental health/psychiatric care, • long-term care and rehabilitation, and • community (kindergarten, school . . .). Supervision of the student nurse on placement has been radically redesigned. Placements are now an essential element of the validation system. Previously, nurse mentor and nurse educators performed a summative assessment of the student on a regular basis in the clinical setting. The summative assessments have now been replaced by a portfolio kept by the student nurse and regularly updated to keep track of their acquired competencies. The ongoing acquisition of competencies must be validated by the nurse in charge of the mentorship of the student.

Problems relating to implementation of the reform The benefits expected from these reforms should not blind us to the challenges that they pose or the controversies that they raise. Debate centres on three issues: elevating nursing science to the status of an academic university discipline, maintaining the nursing profession’s control over its educational mechanisms and developing the role of the nurse educator. It will be useful to consider these aspects in turn.

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What status for nursing science?

Maintaining the nursing profession’s control over its education

To better understand this first controversial issue, we need to both clarify society’s perception of nurses and to outline the main principles of university organization in France, notably as it relates to recruiting lecturer-researchers. Society’s perception of nurses in France is strongly influenced by the dominant position that the medical profession holds in the healthcare domain (Montandon 2006). The majority of the population views nursing care as a practice ancillary to medicine and not as an autonomous professional practice guided by specific research-based knowledge. Although successive reforms in nurse education are seen to be a necessary response to the development of healthcare practices, the same cannot be said for developing nursing research; its social usefulness still needs to be proved in France especially to the medical profession. Within the French higher education context, lecturerresearchers, whether they be readers or university lecturers, are recruited according to their affiliated discipline. The established university disciplines are set out in a national nomenclature accredited by the French National Council for Higher Education (conseil national des universités). Even though the new programme allows for taught credits in nursing science and nursing research funding has been ring-fenced (Ministère de la santé 2009c), nursing science is not an established academic discipline in France. Consequently, lecturer-researchers in nursing science do not receive the same level of recognition as lecturers/researchers in other established disciplines. There are nurses who have been able to undertake these functions during their university careers, but they have done so by attaching to related university disciplines (such as sociology, educational science, etc.) There is currently only one department in France that is involved in teaching and research in nursing science. This nursing department was developed in 2009 within the EHESP School of Public Health. Nurses there act as lecturer-researchers in nursing science and hold an equivalent status within the school to that of their colleagues in other disciplines. However, they are not recognized as lecturer-researchers by the French university system. Integrating nursing science into the French National Council for Higher Education’s nomenclature does not seem to be on the cards. This reticence regarding the inclusion of nursing science as a unique discipline is an obstacle to the process of integrating nurse education into the system of higher education. There is a danger that this could affect the perception of student nurses by creating a distinction between ‘noble’ knowledge taught in contributing disciplines within universities and the ‘less noble’ nursing sciences. This situation could have consequences for the profession’s control over nurse education.

In due course, these reforms could threaten the autonomy of nurse education, especially as the sector is being subject to increasing budgetary constraints and must now publish its performance levels. The French Quality Assurance Agency for Higher Education (AERES) will undertake regular evaluations of the programme’s implementation. It is worth noting the challenges that these evaluations will pose, especially regarding the choice of performance indicators to be applied. There would seem to be difficulties in applying the same expectations and indicators used within the higher education system in general, with the higher value that it places on research, to an educational system in transition. While nurse educators are deeply invested in education, the same is not true for research. This situation stems from their post-diploma education and from the expectations placed on their role to date. Development of activities devolved to nurse educators

The reforms have not considered the development of the role of nurse educator nor, by extension, the directors of the schools of nursing, few of whom hold university qualifications since they have, until now, been educated within MoH structures. Their qualifications allow them to practise interchangeably as nurse educators or as nurse managers in a healthcare unit. Their roles vary from one setting to another, from designing and undertaking educational sequences to instructional design activities. They are more rarely involved in research and publication. A ministerial inquiry is currently considering the development of the nursing health manager role but we are still waiting for decisions. The uncertainties created by these reforms must be speedily addressed given the significant challenges that they present.

Conclusion It is necessary to examine the significance of this reform for nurses and for the nursing profession. For nursing students, this reform brings them closer to ‘full student’ status. The bachelor degree recognition that they receive at the completion of the programme will probably bring them more career opportunities (in nursing but also out of nursing). For nurses working in the public sector, they have had to choose between either being better paid in exchange for working more years before retirement or maintaining the status quo. This situation is due to the budget deficit of the French retirement fund. For the nursing profession more globally, the new pre-registration curriculum increases the workload of staff nurses. They now need to spend more time in mentorship activities. Many of them feel anxious about their future since the great majority does not have a degree at the moment. Their legitimacy is seriously questioned since they are neither faculty nor are they practising clinicians anymore.

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Indeed, nurse educators in university settings are in a unfamiliar territory without a map. As a group, they are desperately in search for guidance. For the nursing profession, this reform represents a challenge but an opportunity as well. Change is always challenging. The reform is also an opportunity since while the MoH provides a broad framework for the nursing curriculum the nursing profession can keep control over the implementation of the programme and educators have total autonomy to teach the nursing content of the syllabus.

Author contributions CD: Drafting of manuscript. FC-D: Drafting of manuscript. OP–dit-D: Critical revision of manuscript. MR-T: Critical revision of manuscript.

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