practice, a challenge that is all the greater in countries where financial resources for education are restricted, learning materials are few, and there is chronic underinvestment in educating teachers.
Nurses have long recognized the need for fundamental change in their education systems, and have struggled long and hard to move the preparation of practitioners beyond the vocational or apprenticeship models. The participants at the Vienna Conference (1) recommended:
All basic programmes of nursing education should be restructured, reori-ented and strengthened, in order to produce generalist nurses able to func-tion in both hospital and community. All specialist knowledge and skills subsequently acquired should be built on this foundation. Nursing educa-tion should include ample experience outside the hospital. Candidates for nursing education should have completed a full secondary education (which may vary from country to country) and have qualifications for
ad-mission that are equivalent to those required by a university or other insti-tute of higher education. The directors of schools of nursing or depart-ments of nursing education, and teachers and supervisors of nursing pro-grammes, must all be nurses.
Legal obligations in respect of nursing education have existed since 1977 in the EU countries. For general nurses, the EC directives require a full -time training of three years covering at least 4600 hours of theo-retical and practical instruction, after a general primary and secondary education of at least ten years' duration. The directives also give guid-ance on the theory and practice elements to be incorporated into the cur-riculum. Almost 20 years after the issuing of these directives, however, not all EU countries are yet able or willing to comply. In 1994, the CE health committee, advised by a working party on the role and education of nurses, produced further guidance on the implementation of educa-tion systems based on the new and changing role of nurses in European societies (25).
Reforms of health systems to meet the changing needs of the popu-lation and the goals of the WHO strategy for health for all imply many
changes for nursing education. World Health Assembly resolution
WHA47.9 (26) urged Member States "to give priority to assessing and improving the quality of basic and continuing nursing and midwifery education ". There is good evidence that nurses themselves soon rose to this challenge, so the problem was less one of persuading the profession than of persuading governments and other decision -makers that invest-ing in nursinvest-ing education was investinvest-ing in health. Some improvements in education have already been achieved and, while the consequences are not always immediately evident in practice, they are among the most im-portant recent developments in nursing.Innovative approaches to curriculum planning and course delivery in nursing education should be supported at the highest levels, so that programmes are (20):
based on the most recent assessment of a country's health needs and the need for nursing services;
problem -based, to promote skills of critical thinking and problem solving;
grounded in the philosophy of PHC;
based on current research in nursing practice;
culturally appropriate; and
multidisciplinary, where appropriate, to encourage shared learning and greater understanding between professions.
A recent WHO Study Group (3) noted two different models of nurs-ing education. In one, the education of nurses is not simply a matter of professional competence but involves wider questions about women's right to participate in higher education and to reap its benefits. The ul-timate goal is to develop nurses' intellectual capabilities as fully as pos-sible, and in the process to enhance the social and career mobility of women whose opportunities might otherwise be restricted. In the sec-ond model, nursing education is simply about teaching people to per-form a range of specific tasks. The Study Group pointed out tensions
between attempting to improve the general education and status of
women through nursing education, and finding an affordable means of ensuring that essential nursing tasks are carried out. Current European reforms in nursing education lie somewhere between these two poles, although closer to the first. There is a growing conviction, with some evidence to back it up, that a well educated practitioner provides better value for money, although she or he is more expensive to train and to pay than a nurse trained only to perform tasks.Many countries are improving basic and continuing nursing educa-tion, as shown in a recent WHO study (5). Nursing education is moving from vocational training to university education, with various stages in between. Nurses and midwives are now educated at university level in many countries. The Vienna recommendations (1) and the 1995 Expert Committee (20) encourage this trend, although the Study Group sug-gested that there is a case for developing programmes at a variety of ed-ucational levels to reflect the need for differing levels of knowledge and skills (7). It said placing basic nursing education in the university might improve the status of nursing and enhance recruitment, but might also encourage élitism and prompt some countries to increase the proportion of unqualified personnel.
The Expert Committee advocated improved opportunities for ma-ture entrants, and the active recruitment of candidates from rural areas and minority cultures. The Study Group noted, however, that, when stu-dents leave their rural communities to be educated in a central, special-ized school of nursing, many do not return, and those who do often find that their education and exposure to outside influences have resulted in
alienation from their own community. Yet small, widely dispersed
schools of nursing may lack the resources and equipment to provide a good education.Finally, the Expert Committee noted that highly educated nurses do not always remain in clinical and public health practice. Inevitably and properly, some become leaders, managers, teachers and researchers.
Many leave clinical work or indeed the profession, however, because of restrictions in the scope of practice and lack of participation in decision -making. Good structures for clinical and public health careers are vital to keep the majority of highly educated nurses in practice.