Nurse educator education in six European countries: a descriptive study / Ausbildung von Pflegepädagog/-innen in sechs europäischen Ländern – eine deskriptive Studie

Little sound knowledge exists about the preparation, selection, or training of nurse educators. Moreover, there is not even an agreed-upon definition of this professional role in Europe (Salminen et al., 2010), though other regions of the world have already made greater progress in this regard. In the US, for example, the National League for Nursing (NLN) defines nurse education as a “speciality area and an advanced practice role within professional nursing” (NLN, 2012, 5). The NLN has published a scope of practice for academic nurse educators, defined eight core competencies, and developed a nationwide certification programme that establishes educational standards for this speciality area of practice and scholarship (Caputi, 2019; Halstead, 2018). In their publication about nurse educator competencies, the SREB Council in Collegiate Education for Nursing describes a nurse educator as “[…] a skilled health-care provider who meets professional nursing standards and has graduate nursing preparation as an advanced generalist or specialist” (SREB, 2002, p. 2). Some American authors stress the importance that nurse educators “[…] be prepared to serve as educators [and] researchers, and […] have experience in a clinical specialty area” (Booth et al., 2016, p. 54), while others emphasise the complexity and diversity of this role: “Nurse educators teach in academic institutions and in a variety of healthcare agencies. They educate nursing students at all levels, from certified nursing assistants to doctorally prepared current and future nurse educators, clinicians, and researchers” (Oermann & Frank, 2018, p. 3). Nurse educators are seen as a key resource in preparing the next generation of nurses; consequently, a great deal of attention is paid to the education and competencies of these educators (NLN, 2002, 2012).

With a similar intention to that of the NLN, in 2016, the WHO launched the Nurse Educator Core Competencies as part of the “Global strategy on human resources for health: Workforce 2030” and the updated “Global strategic directions on nursing and midwifery 2016–2020” (WHO, 2016, p. 5). Although the document does not define the term “nurse educator”, it does provide some characteristic features of the role. The WHO (2016) explains that nurse educators teach theoretical and practical content to students in institutions that provide degree education in nursing. According to the WHO, nurse educators are also responsible for implementing and managing educational offers (teaching classes, lectures, seminars) and for assessing the results of these offers (WHO, 2016). According to the WHO (2021), however, standards or requirements for the educational preparation of nurse educators are not addressed, nor is the question of whether nurse educators are responsible only for theoretical and practical teaching in lecture halls or seminar rooms or also for the education of nursing students in skills labs and clinical settings.

A systematic literature search was performed between December 2020 and March 2021 in relevant databases (Cinahl, Embase, Eric, Medline, PsycInfo, Psyndex, Web of Science Core Collection), to find literature on nurse educator education in Europe. Search terms were systematically combined using the SPICE scheme (Booth, 2006), as shown in Table 1. The search strategy was extended via a manual search of four previously defined nursing journals that focus on nurse education (Journal of Nursing Education and Practice, Nurse Education Today, Nurse Educator, and Teaching and Learning in Nursing), and a snowball search of reference lists from all full texts that were included was performed. The search was limited to literature in English only and to an earliest publication date of 2000 due to the 1999 Bologna process, which significantly changed European education systems.

In order to be included, records had to address the topic of nurse educator education. If the content of a record was (a) about nurse education or (b) about nurse educator education not within the selected European countries (DE, ES, FI, MT, SK, UK), the respective records were excluded. No restrictions were defined for publication type or quality; however, study designs were reported and discussed. Two researchers independently screened titles, abstracts, and full texts for inclusion and exclusion criteria. Discrepancies were discussed until an agreement was reached.

Only six studies could be identified with detailed information on the preparation, selection, and training of nurse educators: two qualitative studies (Janhonen & Sarja, 2005; Råholm et al., 2016), two quantitative studies (Salminen et al., 2009; Koivula et al., 2011), and two literature reviews (Spitzer & Perrenoud, 2006; Jackson et al., 2009). Four studies were conducted in Scandinavia, and the two literature reviews focus on European countries. The studies were published between 2005 and 2016, with five studies being more than ten years old. The studies focus on nurse education reform (Spitzer & Perrenoud, 2006), the structure of nurse educator education (Jackson et al., 2009), identity development during nurse educator education (Janhonen & Sarja, 2005), the readiness of nurse educator candidates to meet the requirements of nurse educators during teacher training (Salminen et al., 2009), research utilisation in teaching (Koivula et al., 2011), and the role of and future challenges to nurse educators in nurse education (Råholm et al., 2016).

In some of the identified studies, the different working environments and the wide range of tasks that nurse educators undertake are discussed (e.g. education/teaching, research, clinical practice, management). Since these tasks are interrelated but also competing, the expectations placed on nurse educators are described as ‘ambiguous’, ‘unrealistic’, ‘frustrating’, ‘contradictory’, and as creating ‘obvious tension’ (Spitzer & Perrenoud, 2006, p. 154; Jackson et al., 2009, pp. 118, 119; Raholm et al., 2016, pp. 76, 78, 79).

All identified studies address the transfer of nurse education from secondary to tertiary education that has taken place in most countries in Europe over the last decade. There is consensus across the identified studies that this transfer of nurse education to tertiary education challenges the academic credibility of nurse educators and increases the demands on these nurse educators’ education, especially in their role as scholars. This consensus suggests—inter alia—that a more intensive examination of the preparation, selection, and education of nurse educators is needed in order to ensure realising the WHO's ambitions of achieving a skilled global nursing workforce.

The literature search showed that the education of nurse educators in Europe is scarcely described in international research articles. Due to the limited results of the literature search, the results were not published separately, but integrated into the present article and used as a basis for this article's questionnaire survey.

The aim of the present descriptive study is to provide an overview of the educational framework (including regulations and standards) for nurse educator education in the six European countries that are currently participating in an Erasmus+ project. The documentation and comparison of the information may enable further reflection on the potential future design and harmonisation of nurse educator education in Europe and may also help to promote global discourse on this topic. The research questions are the following: -

What legal regulations, requirements, and standards for nurse educator education can be identified?

A descriptive international cross-sectional comparative study was conducted. The data were collected via an online questionnaire that had been completed by experts on the education of nurse educators from the participating countries and by representatives of national nursing organisations with specialist knowledge within their country about nurse educator education. The study was limited to the countries involved in the ERASMUS+ project and represented different geographical areas of Europe: Northern Europe (FI, UK), Western Europe (DE), Southern Europe (ES, MT), and Eastern Europe (SK) (IUPUI, 2021).

Purposive sampling was used. The survey was distributed among the project partners at the universities in the participating countries (n = 6) and among the representatives of national nursing organisations (n = 6) that are members of the International Council of Nurses (ICN), the European Forum of National Nursing and Midwifery Associations (EFNNMA), and/or the European Federation of Educators in Nursing Science (FINE). Participants from the University of Turku (FI), the University of Malta (MT), the University of Edinburgh (UK), the Constantine the Philosopher University in Nitra (SK), the Universitat lnternacional de Catalunya (ES), and the Humboldt Universität zu Berlin – Charité – Universitätsmedizin Berlin (DE) were recruited. All of the partners are experts in the education of nurse educators or have special knowledge about the conditions in their own country on this subject. The representatives of the national nursing organisations were deemed to have specialist knowledge about the education of nurses and nurse educators as well as a general understanding of the regulations and standards in their own country.

An online questionnaire using a quantitative semi-standardised design was developed in the research team based on the literature on this topic. The questionnaire was discursively coordinated and pre-tested with nurse educators (n = 6) who were participating in the Erasmus+ project. Feedback was gathered in order to check cultural aspects among countries, to ensure the clarity and applicability of the tool, and to identify problems that may occur during data collection. In addition, the questionnaire wording was compared with that of questionnaires from (vocational) education research (OECD, 2018; OECD, 2018a; Schleicher, 2020; OECD, 2021) and was adapted to align with the wording of these other questionnaires in order to ensure comparability. In this way, it was possible to ensure that the questions were fully comprehensible in different countries that have different procedures for nurse educator education. The questionnaire consisted of a total of 22 items with two open and 20 closed questions and six subcategories, which examined the topics of country (1 item), authorities (4 items), requirements (7 items), structure (6 items), programme design (3 items), and working environment (1 item). The survey was conducted in English in all participating countries.

The questionnaire was digitally distributed via email using SoSciSurvey. Data were collected during March and April 2021. Participants from universities (nurse educators) were recruited to answer the questionnaire by the members of the project team. Participants of the national nursing organisations were contacted via email and were asked to provide competent contact persons, who were then sent the questionnaire. Data privacy and confidentiality were maintained and protected. Participants received a privacy and information letter before completing the questionnaire. The EU General Data Protection Regulation was considered based on the specifications of Charité – Universitätsmedizin Berlin. Participants received a reminder to complete the questionnaire two weeks after the start of the survey and one week before the end of the survey. One questionnaire remained unanswered, and all others were completed in full (n = 11).

Data were analysed descriptively. Two researchers organised and condensed the data. In the event of discrepancies between responses, data were submitted to the project partners for clarification, re-verification, and validation. Finally, the collected information was analysed for similarities and differences between the countries included in the study and was compiled in a comparative tabular overview.

According to the WMA Declaration of Helsinki (1964) on ethical principles, ethical approval was not required for this study. No personal data were collected, and the participants of the survey do not belong to any vulnerable group. Participants were fully informed before the survey and provided their consent; they took part voluntarily in the online questionnaire.

The legal regulation of nurse educator education varies in the six European countries included in the study (Table 2). In some cases, the requirements for nurse educators are formally defined by competent authorities and national laws (DE, FI, MT, SK), and in most of the participating countries, ministries are responsible for supervision. Only in the UK is there no such scrutiny of the educators’ educational preparation; instead, the Nursing and Midwifery Council makes stipulations for practice supervisors and assessors and monitors the higher-education institutions that provide education. Although Germany consists of 16 federal states, minimum requirements for nurse educators are uniformly regulated at the federal level by the Nursing Professions Act (latest version from 2020). In ES, FI, MT, SK, and the UK, nurse educators are subject to the same requirements as are other academics in higher education, and nursing-specific requirements are not formulated. The requirements for nurse educator education are highly heterogeneous across the six European countries.

Different standards exist concerning educational offerings for nurse educators: Programmes are available in the form of basic or continuing education at almost all qualification levels of the European Qualifications Framework (EQF), ranging from EQF level 4/5 to 8. For the most part, however, the educational level seems to centre around EQF 7 (master's level). The subject focus of study programmes can vary from pedagogy or anthropology to sociology, with the health sciences being the most common focus (Table 3). In most – albeit not all – countries, a license or registration as a nurse by either a state agency or a professional self-governing organisation is a prerequisite for entering a nurse educator education programme.

Mandatory qualification requirements for nurse educators also vary from country to country. In FI, nurse educators must have either (1) a master's degree that most often focuses on the health sciences or on pedagogy and that is recommended to require 60 credits in pedagogy (following the European Credit Transfer System ECTS) or (2) a PhD with a focus also mostly on the health sciences or pedagogy. Moreover, nurse educators in FI must be qualified in a healthcare profession at the bachelor's level and must have at least three years of work experience in healthcare. In SK, it is also mandatory for nurse educators to have a master's degree as a nurse educator. However, nurse educator education can proceed either on the master's level or on the doctoral level, both with a focus on health sciences. In ES, nurse educator education takes place on the doctoral level with a focus on health sciences. That means that of the countries examined here, ES requires the highest level of education. This requirement is regulated by the National Agency for Quality Assessment and Accreditation of Spain (ANECA) and requires that at least 50% of teaching hours be completed with educators who hold a doctoral degree. Moreover, the agency also regulates the percentage of permanent staff at a university and sets a maximum of 40% for clinical educators. In MT, the mandatory educational level for nurse educators is a master's degree with a focus on pedagogy, the health sciences, anthropology, or sociology. For permanent tenure, a doctoral programme must be successfully pursued. In the UK, educational programmes that qualify nurse educators are on the master's or doctoral level with a focus on the health sciences. Depending on the university, a PhD may be required to apply for lectureships, but in general, there is no mandatory educational level defined for nurse educators. In DE, nurse educators can be qualified via further education programmes or via programmes on the bachelor's or master's level, each with a pedagogical focus. As a rule, educators in DE must have at least the qualification sought by the respective learners (e.g. in vocational training, at least a vocational qualification and relevant further training are required). According to the Nursing Act, a master's degree or the equivalent is mandatory only for nursing school directors and for a ‘reasonable proportion’ of nurse educators in DE. Nurse educators with a PhD are rare in DE and can be found either in management positions at educational institutions or in higher-education programmes.

Formal education programmes for nurse educators are offered in only half of the six surveyed European countries (Table 4). In DE and FI, these educational programmes conclude at the master's level (EQF 7) at universities or at universities of applied sciences. They comprise 60–120 credits (ECTS), and they can be taken up as full-time or part-time studies. In FI, the master's degree includes 60 credits (ECTS) of professional pedagogical studies. In the UK, these education programmes for nurse educators are certificate programmes at universities, which are part-time studies and comprise 60 credits (ECTS). The financing of these educational programmes is regulated differently in the three countries: In FI, funding is provided by public funds. The same applies to DE at state universities and at universities of applied sciences only, whereas tuition fees are charged at private universities and at universities of applied sciences. In the UK, certificate programmes are free of charge, but students must be in post in order to participate.

Competence standards and compulsory topics in nurse educator education could not be identified. Universities in the different countries investigated appear to have autonomy in their ability to independently create curricula for nurse educator education; therefore, subjects and expected learning outcomes differ across the nurse educator programmes identified in this study.

Working environments and tasks for nurse educators are not conclusively defined. Most nurse educators are qualified for teaching at higher-education institutions. Germany is once again an exception here as nurse educators in DE are primarily educated for teaching at secondary vocational schools.

Developing educational projects and teaching in classrooms, in digital environments, or in skills labs are common tasks for nurse educators in most of the investigated countries. However, nurse educators are expected to merge and reconcile numerous roles in their daily work (Table 5). Research is seen as one of the tasks of nurse educators in all countries. Clinical teaching is not always seen as a working environment for nurse educators in the different countries and is thus subject to different specifications.

There are some limitations in this study that should be considered. Due to the purposive sampling employed, only a small number of countries were selected for participation. Thus, this study's results represent only a portion of nurse educator education in European countries. Consequently, the collected information was limited, and both the transferability and generalisability of the findings to other countries and to the wider pan-European context should hence proceed with significant caution. Regarding the selection of study participants from members of the ICN, the EFNMMA, and/or the FINE, the validity of the responses cannot necessarily be ensured because respondents on behalf of the nurse organisation may themselves not have been nurse educators or even experts in nurse educator education.

Nevertheless, developing a questionnaire collaboratively and surveying the participants and representatives of corresponding nurse organisations served as a good starting point. This method offered interesting insights into requirements and standards in the participating countries and may stimulate further research and development in the field of nurse educator education.