Towards the Future: The Education of Nurses in Iceland Reconsidered
12.6 Educational Reforms of the Undergraduate Nursing Education
12.6.1 Educational Qualifications for Entry Into Practice
Iceland was one of the 29 countries that signed the Bologna Declaration in 1999 which emphasised free movements of students between countries. A common structure of 3-year BS programmes (180 ECTS), 2-year MS programmes (120 ECTS) and 3-year doctoral programmes (180 ECTS) was agreed upon. This has called for educational reforms in many countries to enhance comparability as nurs- ing education in the European countries varies. The 4-year BS programme in Iceland has been among the longest. The revised programme in Iceland is still 4 years (240 ECTS) and together with occupational therapy the only 240 ECTS BS programmes in the country, while other programmes have adjusted to the Bologna structure. For other professions needing a licensure to practice such as teachers, physiotherapists and lawyers, an MS degree is required for the licensure. The nurs- ing society in Iceland including faculty of nursing from the University of Iceland, the University of Akureyri, representatives from the Icelandic Nurses’ Association and from the National University Hospital and the primary health care in Reykjavik evaluated carefully what would be best for nursing education and practice in Iceland, with three reports being written on the subject [29, 34, 35]. What was mainly addressed was the qualification required for entry into practice, an MS degree or a BS degree. All three reports concluded that a BS degree should qualify as entry into practice. The experience from the School of Education was that after the MS degree was made a requirement for license, applications to the school dropped from 263 students in 2011 to 119 in the year 2017. That coupled with a long standing lack of nurses [36] and low reimbursement in comparison to similar professions [37] contributed to the conclusion that it was and is not considered feasible for nursing to make the MS degree entry into practice. In order to meet the mismatch between the lengths of BS programmes in Iceland, nurses with a mini- mum of first grade from their BS studies will be granted 30 ECTSs into their mas- ter’s studies, thereby acknowledging that a part of the BS programme is at a master’s level.
12.6.2 The Revised Programme
The generation of students who currently are enrolled in nursing were born in the years 1985 to 2005, referred to as the millennials. This generation has been described
12 Towards the Future: The Education of Nurses in Iceland Reconsidered
as highly protected and overscheduled [38], raised to be winners and to be special [39]. They prefer to work in groups with hands-on experience and place less value on reading and listening to lectures [40]. The millennials differ substantially from previous students which have called for new ways of working with and educating students. To address this situation, the revised educational programme was devel- oped in close collaboration with students, discussing pros and cons of the older programme and what the students considered in need for change.
The above analysis of nursing education and practice and societal changes has guided us and we have drawn on many of the suggestions put forward by Benner and her associates in reforming the curricula [16, 41]. One of the main ideas that we have found helpful is the stress placed on seamless integration of theoretical and clinical education emphasising the development of clinical reasoning among students. Such reasoning is situational and contextual, taking both the patient’s often complex health and social condition into consideration as well as families, friends and the community at large. Working within this tradition demands atten- tion to multiple ways of knowing [5, 42] and ample mentoring in the clinical area to develop nuanced skills in attending to issues confronting nurses in their daily work.
Two thirds of the revised undergraduate programme are designated to nursing science and one third to the basic sciences. Emphasis is placed on assuring continu- ity in the curriculum and preventing repetition. Furthermore, specialists in certain areas such as wound management and pain have been appointed to manage their topic and make sure it is well covered throughout the curriculum. Although there is a long tradition in the undergraduate programme of using a variety of teaching methods such as the skills lab, clinical practicum, written assignments, conferences, case studies, problem-based learning and group projects, the new generation of stu- dents has called for even more participatory teaching approaches and less emphasis on formal lectures. Our skills lab was developed into a simulation centre which has allowed for more space and significance of interactive learning in the curriculum and helped the students to become more proficient in clinical skills before they enter clinical placements. A number of our lectures have also been transformed in line with flipped teaching and web-based learning. Students are introduced to clinical nursing during the first semester of the undergraduate programme. Increased emphasis is on evidence-based practice; information technology in nursing practice;
welfare technology, particularly in the care of older people; and clinical compe- tence. Integration of theoretical content and development of clinical competencies has been of central importance along with research as students are given opportu- nity to work with faculty on their research projects. One of the goals in the strategy of the university is that faculties and study programmes should systematically inte- grate teaching and research. That should be achieved by having active researchers being involved in teaching first-year undergraduates. This is accomplished at all years at the nursing faculty since faculty teachers are involved in research and teach at all stages of the programme.
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12.6.3 The Clinical Learning Model: A Community of Learning Creating a successful collaboration between academia and practice is fundamen- tal for effective clinical learning of students [43]. A major assumption behind the curriculum is that nursing is a practice-based profession and that clinical learning is instrumental in all nursing education. Strengthening the clinical education is a major objective in the revised curricula with the aim of assisting the students in developing and gaining practical skills and preparing them for complicated, mul- tifocal and constantly changing working environment. Studies have found that it is highly important to foster a student-centred environment by listening to stu- dents; offering additional support; providing constructive feedback and clear, well-planned assignments; facilitating the meeting of individual learning needs and innovation; and promoting student voice [44]. In the clinical setting, we have attempted to meet this by training clinical teachers. The final responsibility and organisation of the clinical teaching (competencies, length of study period, clini- cal assignments and the overall quality of the education) is held by the faculty of nursing, with the supervision of clinical teaching being dependent on nurses at the clinical sites. We have two levels of ‘formal’ teachers at the clinical site. Firstly, there are clinical instructors (CIs) who work in the clinic but are also reimbursed by the university and work closely with the faculty in developing clinical learning/
teaching/assignments. Most are clinical nurse specialists with MS degrees. The CI is responsible for the clinical experience to be coordinated according to clinical competencies of each clinical course. The CI meets students weekly, gives feed- back on clinical work, engages in clinical reasoning, encourages independence and fosters critical thinking based on evidence. The CI is also responsible for clinical seminars where clinical reasoning and decision-making is further encour- aged by clinical cases with the aim of increasing their ability to know the nature of patients’ needs that change over time. Finally, the CI supervises the students with assignments related to their clinical learning and evaluates them. The second level of clinical teachers is clinical preceptors (CPs). They work in the clinical area, hold a BS degree, have a minimum of 2 years of clinical experience and are often selected on the basis of their willingness to have a student. CPs supervise and plan daily the basic clinical skills trained according to the clinical competen- cies of each course and make full use of the learning opportunities of the clinical situation with the student. At the end of the clinical study period, CPs are respon- sible for assessing the students’ performance and providing feedback. The CIs support the CPs in their work with the students [41]. In order to increase and sustain the collaboration between the faculty, CIs and CPs seminars are held yearly or every semester, where theories on and practice of clinical teaching is discussed and the teachers reflect on their teaching experience. Students are a part of this seminar. This has been effective in enhancing the clinical learning environ- ment and is constantly being reviewed and reorganised based on comments from participants.
12 Towards the Future: The Education of Nurses in Iceland Reconsidered