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Nurse education

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Nurse education consists of the theoretical and practical training provided to nurses with the purpose to prepare them for their duties as nursing care professionals. This education is provided to student nurses by experienced nurses and other medical professionals who have qualified or experienced for educational tasks, traditionally in a type of professional school known as a nursing school or college of nursing. Most countries offer nurse education courses that can be relevant to general nursing or to specialized areas including mental health nursing, pediatric nursing, and post-operative nursing. Nurse education also provides post-qualification courses in specialist subjects within nursing.

A nursing student can be enrolled in a program that leads to a diploma, an associate degree, or a Bachelor of Science in nursing.[1][2]

Historical background

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Nurses at Okinawa Central Hospital Nursing School in 1946
 
The nursing school at Karanda Mission Hospital, Zimbabwe

During past decades, the changes in education have replaced the more practically focused, but often ritualistic, training structure of conventional preparation. Nurse education integrates today a broader awareness of other disciplines allied to medicine, often involving inter-professional education, and the utilization of research when making clinical and managerial decisions. Orthodox training can be argued to have offered a more intense practical skills base, but emphasized the handmaiden relationship with the physician. This is now outmoded, and the impact of nurse education is to develop a confident, inquiring graduate who contributes to the care team as an equal. In some countries, not all qualification courses have graduate status.[citation needed]

Traditionally, from the times prior to Florence Nightingale, nursing was seen as an apprenticeship, often undertaken in religious institutes such as convents by young women, although there has always been a proportion of male nurses, especially in mental health services.

In 1859, Valérie de Gasparin and her Husband Agénor de Gasparin opens the first nursing school in the world in Lausanne, Switzerland : L'École La Source [fr]

Some other nurses at that time, notably Ethel Gordon Fenwick, were in favor of formalized nursing registration and curricula that were formally based in higher education and not within the confines of hospitals.

Nurse education in the United States is conducted within university schools, although it is unclear who offered the first degree level program. So far as known Yale School of Nursing became the first autonomous school of nursing in the United States in 1923.[3]

In November 1955, a World Health Organization (WHO) study group on the education of nurses met in Brussels and made several recommendations, including that "At least one experimental school of nursing be set up in each country."[4] In the UK, the first department of Nursing Studies at the University of Edinburgh was established in 1956, with a five-year integrated degree programme introduced in 1960.[5] Several other universities across the UK during the 1960s. In 1974 La Trobe University commenced the first nursing course in Australia.[6]

United Kingdom

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Florence Nightingale was one of the pioneers in establishing the idea of nursing schools from her base at St Thomas' Hospital, London in 1860 when she opened the 'Nightingale Training School for Nurses', now part of King's College London.[7] Her intention was to train nurses to a qualified and specialized level, with the key aim of learning to develop observation skills and sensitivity to patient needs, then allow them to work in hospital posts across the United Kingdom and abroad.[8] Her influence flourished and nursing is now a course taught at a number of British universities.[citation needed]

Rebecca Strong OBE (1843–1944) started a Preliminary Training School for Nurses at the Glasgow Royal Infirmary in 1893. She had been working as a Matron there since 1879.[9] This 'block apprenticeship' programme had separate classroom based teaching and practical periods on the wards. Two courses were arranged in conjunction with the Professors of St. Mungo's College - a three-month course consisting of elementary Anatomy, Physiology and Hygiene. If these exams were passed a second course was given which consisted of Medicine, Surgery and Practical Nursing.[10] The prospective nurse was then able to enter the hospital with this theoretical knowledge. Strong was supported by the pioneering surgeon Sir William Macewen.[11]

Eva Luckes, Matron of The London Hospital (1880–1919) was mentored by Florence Nightingale, and was her friend and disciple.[12][13][14]Eva Luckes was another innovator in nurse training and education and introduced the Preliminary Training School concept to England in 1895.[14][12][13] This was adopted as an element of mandatory training programme following the 1919 Nurse Registration Act. Eva Luckes produced over 470 matrons who filled posts at home and abroad, including three who filled the top positions in Military Nursing, Ethel Becher, Sarah Oram and Maud McCarthy.[13] Luckes's other matrons also spread her style of "Nightingale nursing" to voluntary hospitals and infirmaries both in the provinces and London. They included Annie McIntosh, Matron of St Bartholomew's Hospital, 1910–1927.[13]

Apart from the nursing school of King's College London, the direct descendant of Nightingale's school, the University of Manchester was one of the first English institutions to offer the course at degree level.[15] A new building for the Manchester Medical School was opened in the early 1970s and degree courses in nursing were established about the same time. Nursing education at the university expanded greatly in 1996 when a new School of Nursing and Midwifery was created by transferring the Manchester College of Midwifery and Nursing into the university's Faculty of Medicine, Dentistry and Nursing.[16]

Nursing education in the United Kingdom was significantly influenced by the Briggs Report of 1972.[17] This set a new agenda for nursing and nurse education and sought to develop a career progression away from the bedside into education, management and research.[18] In addition, the 1979 Nurses, Midwives and Health Visitors Act provided the legal mechanism for change.[19][20] This saw a gradual movement away from practice-based training towards a college-based system of education, from the nurse apprentice to the supernumerary nurse.[21]

Entry level courses, sought by most universities, are often five Standard Grades/GCSEs, including English, maths and a science (preferably biology), and two Highers/A-Levels. Mature students, over the age of twenty-one, have the option of entering upon completion of a college Access course, and experience in jobs related to health/nursing assistance are also worthy for consideration into the course.

Currently, nursing is a three-year course in the UK, with students choosing the branch that they want to study, e.g., adult, child, mental health, or learning disability; or combinations of two (called dual-field). The course consists of a balance between coursework in classes and practical placements in a health care setting. The first year is foundation, where students learn anatomy and physiology and basic health care. Newly qualified nurses then have to register with the Nursing and Midwifery Council in order to apply for jobs and legally practice.

United States

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The history of nursing education had a long and varied role in the United States. Before the late 1800s little formal education was available to train nursing students. Education was primarily based on an apprenticeship with a senior nurse who taught bedside care within a hospital or clinic setting. Over time this model changed dramatically. A short chronology of Schools of Nursing in the United States is:

 
The nursing pin awarded to graduates of the nursing school at Sacramento State University in the USA.
  • In 1873, the Bellevue Hospital School of Nursing, of New York City, was founded. It was the first school of nursing in the United States to be founded on the principles of nursing established by Florence Nightingale. The School operated at Bellevue Hospital until its closure in 1969.
  • 1883: The Medical University of South Carolina College of Nursing has been traced to its beginning in 1883 when the South Carolina Training School for Nurses was established at the request of Roper Hospital (known then as City Hospital) in Charleston, SC.[22] Due to an earthquake in 1886 which destroyed the City Hospital, the effort only lasted a few years. However, once the new hospital was built the nursing program was reestablished in 1895 as the Charleston Training School. In 1916, the Board of Commissioners of the Roper Hospital proposed the transfer of the training school to the Medical College of the State of South Carolina, whose school of medicine had been established in Charleston in 1824 and whose faculty was already providing most of the nursing instruction. The proposal was accepted by both the hospital and the Medical College, and in 1919 the Roper Hospital Training School for Nurses became the School of Nursing of the Medical College of the State of South Carolina. In 1969 when the Medical College was designated the Medical University of South Carolina, the School of Nursing became the College of Nursing.[23]
  • 1889: The University of Maryland School of Nursing (UMSON) was founded with Louisa Parsons as temporary head. She was trained at the Nightingale Fund School at St. Thomas' Hospital in London and was decorated for her service in several conflicts.[24][25] UMSON is one of the oldest and largest nursing schools in the United States.[26]
  • 1889: The Johns Hopkins School of Nursing was founded in conjunction with the creation of the Johns Hopkins Hospital. As one of the earliest hospital-based nursing schools in the United States school leaders consulted with Florence Nightingale on the program of education. These same nurse leaders also established what would become the National League for Nursing Education and helped in establishing the American Nurses Association.[27]
  • In 1909, the University of Minnesota offered the first university based nursing program. It offered the first Bachelor of Science in Nursing degree and graduated the first bachelor's degree educated nurse.[28][29][30][31]
  • By 1916, 13 universities and 3 colleges had developed bachelor's nursing degree programs.[29]
  • In 1923, the Yale School of Nursing was founded. It became the first School of Nursing to adopt the educational standards from the 1923 Goldmark Report that was requested by the Rockefeller Foundation. The curriculum was based on an educational plan rather than on hospital service needs.[32]
  • In 1956, the Columbia University School of Nursing became the first in the United States to grant a master's degree in a clinical nursing specialty.[33]

Nursing qualifications

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There are multiple entry levels into nursing. This has led to confusion for the public, as well as other healthcare professionals. The earliest schools of nursing offered a Diploma in Nursing and not an actual academic degree. These are either a Certified Nursing Assistant (CNA) certificate or a Licensed Practical Nurse (LPN) certificate or diploma. Community colleges began offering an Associate of Science in Nursing degree, and some diploma programs switched to this model. Universities then began to offer Bachelor of Science in Nursing and Bachelor of Nursing degrees, followed by Master of Science in Nursing degrees, and Doctor of Nursing Practice degrees.[34] A Doctor of Philosophy Degree in Nursing (PhD) is also available, although this degree tends to focuses more on research than hands-on patient care.[citation needed]

Nursing degrees in the UK

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Pre-registration nurse training and education in the UK is now via a bachelor's degree (a UK Level 6 qualification)[35] or a 2-year pre-registration master's degree at level 7, following the phasing-out of the Diploma of Higher Education (a UK Level 5 qualification)[35] in Nursing which was previously offered at universities and colleges.

To become a student nurse, individuals must apply through the university and Colleges Admissions Service (commonly referred to as "UCAS") to their nursing degree choices, choosing from one of the four nursing fields: Adult, Children, Mental Health and Learning Disabilities. Requirements for entry to a pre-reg nursing degree are usually five GCSEs (including mathematics, English language and at least one science subject) at Grade C or above, along with three A-Level subjects (preferably but not essentially science-based) at Grade C or above, although the majority of universities will seek higher grades due to the competition for places. Key Skills courses are generally no-longer accepted as an alternative to GCSEs, however science or healthcare-based BTEC Level 3 Extended Diplomas and Access courses are most oftem accepted in lieu of A-Level qualifications.[citation needed]

If successful following interview, the student will study a "core" first year, learning basic nursing competencies essential to all four of the above fields. It is then from second year and onwards that the degree will begin to focus on the student's chosen field. Following completion of the degree, the applicant will be registered with the Nursing and Midwifery Council (NMC) as a Registered Nurse in their field of practice, using the post-nominal RNA, RNC, RNMH or RNLD as appropriate to their degree qualification.[citation needed]

United States curriculum

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Pre-requisites often include math, English, and other basic level courses. Basic courses in biology, anatomy and physiology are required. Depending on the nursing school, credits can be taken elsewhere, and transferred in, although limitations on time span between taking pre-requisites and applying to nursing programs often exist, usually around 5 years, although some schools set no parameters.

Core coursework includes anatomy, physiology, pathology, and pharmacology. Additionally, a strong emphasis is placed on procedural education such as insertion of intravenous and urinary catheters, sterile dressing changes, proper administration of medications, physical examinations, caring bedside manner, and other vital skills. After the first semester basic skills are obtained, students rotate through obstetrics, mental health, medical, surgical, oncology, critical care and pediatric units to get a holistic view of nursing and what it encompasses. Many nursing students and nursing schools use medical and healthcare educational software as a study or training aid.

Many schools offer an accelerated bachelor's degree in nursing program. A variation of the Second Degree BSN is the Accelerated BSN. In addition to giving credit for having completed liberal arts requirements, an Accelerated BSN program allows students to complete their undergraduate nursing program's course requirements more quickly than students enrolled in a traditional BSN program. Accelerated BSN programs usually take 12 months to complete, though some programs may run for 16 to 24 months.

The traditional BSN programs may take much longer time. For example, in California, where nursing is a relatively high-paid and in high demand profession, the completion of BSN (including pre-requisites, major courses in the program, and General Education courses of college) may take 5 to 6 years. A 3.0 GPA is often an entrance requirement for many programs. Some more prestigious schools require much higher GPA score to be competitive. Many programs now also require TEAS-V test scores to evaluate potential students for entry. Also, there are other options of Associate Degree for RN and LPN programs (which in term of nursing training is much shorter and the scope of practice is different than RN). Lastly, the Master level is for experienced RNs to reach a higher education and may expand their scope of practice.

Nursing students today have a wide variety of program options that range from state colleges or universities to private, for-profit entities. Nursing programs that are accredited offer program content that meets the national and state level standards.[36] The U.S. Department of Education identifies that the act of accreditation may support programs of study that continually assess their quality of education, strive to offer improvements when needed, utilize faculty and staff when planning and implementing program evaluation, and standardizing criteria specific to professional certificates and licensure.[36] Ensuring that curriculum is up-to-date, relevant, and current to the happenings within nursing and healthcare today, may be better obtained through an accredited nursing program. Nursing students that choose an accredited nursing program could receive federal financial aid and might successfully transfer course credits to another accredited program. These benefits may not be available for students that utilize a non-accredited program. There are two main accrediting bodies for nursing programs. The Accreditation Commission for Education in Nursing (ACEN)[1] and the Commission on Collegiate Nursing Education (CCNE)[2].[36] Both accrediting bodies are sufficient to ensure that nursing programs meet national standards. ACEN provides accreditations for all levels of nursing programs; this includes the practical nurse through the doctorate. CCNE provides accreditation for the bachelorette and master's nursing programs.[36]

In the United States, students graduate from nursing education programs qualified to take one of the NCLEX (National Council Licensure Examination) exams, the NCLEX-PN for Licensed Practical Nurses (LPNs) or the NCLEX-RN for Registered Nurses (RNs).

Continuing education

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After the Nursing student becomes a Registered nurse, he or she is required to participate in continuing education to retain their licensing and registration.[37] In 2010, it was projected that by 2018, there would be a 22% job growth in the nursing field; at the time it was the United States' fastest growing occupation.[38]

Scope

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Nursing education includes instruction in topic areas. These are nursing assessment, nursing diagnosis, and nursing care planning. In the United States, nursing students learn through traditional classroom and lab instruction. Nursing education also involves clinical rotations and simulation, throughout their schooling, to develop care planning and clinical reasoning. At the end of schooling, nursing students in the US and Canada must take and pass the NCLEX (National Council of Licensure Examination) to practice.

Nursing specialties

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There are a variety of areas where nurses can specialize in and they may decide they want to be qualified in one or several specialties over the course of their career. There are four main branches of nursing: Adult nursing, Children's Nursing, Mental Health Nursing and Learning Disability Nursing.[39]

Present aims

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Among nurse educators, arguments continue about the ideal balance of practical preparation and the need to educate the future practitioner to manage healthcare and to have a broader view of the practice. To meet both requirements, nurse education aims to develop a lifelong learner who can adapt effectively to changes in both the theory and practice of nursing.[40]

Medical simulation and hands on learning are common among nursing education practices. Some nursing schools will carry out hands on demonstrations and practice so that future nurses can learn skills like how to administer specific medications and care for specific patients such as the skills taught in an opioid care training course.[40] While it is clear that the use of Medical simulation in nursing education is important for improving practice, patient safety, and interprofessional team skills, the balance of simulation to clinical time remains in the hands of the institutions.[41]

Although nurses tend to spend a lot of time in nursing school doing simulation and clinical learning, they also spend time in the classroom learning about the care that they will eventually give. This includes both broad science courses as well as very specific courses such as a course specifically about how to better care for addiction patients.[42]

Additionally, newer curriculums within nursing education are requiring future nurses to be educated on patient and workforce diversity. A large step in increasing diversity within nursing is through education. Several research studies have shown diverse patient populations cycle through hospitals on a regular basis and a patient's needs are never the same. It is a nurse's job to cater to their needs, and ensure the patient is being treated well.[43] During their education, nurses will master the practice of engaging, communicating, and treating unique patient populations, while working with diverse coworkers.[44]

The American Association of Colleges of Nursing (AACN) [3] has created The Essentials to identify curriculum content and student competencies that should be met for all bachelorette, master's and doctoral level nursing students.[45] Most recently The Essentials underwent an overhaul that resulted in the competencies and sub-competencies of each domain, be taught with a focus on competency-based education and assessment.

Academic integrity and nursing education

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Within the undergraduate student population, over 70% have self-reported participating in some form of academic misconduct or dishonesty within the classroom setting.[46] Academic integrity within nursing education programs should be prioritized as research states that dishonest behaviors in the classroom setting may increase the likelihood of clinical dishonesty. This could impact patient safety and outcomes.[47] Nursing programs could begin to address academic misconduct in the classroom by leaning into Bandura's Social Learning Theory (SLT). The SLT posits that students learn behaviors from observing, imitating, and modeling.[48] A variety of educational tools may be implemented to help shape the student's perceptions of dishonest behaviors. Some curriculum, simulation, and experiential learning experiences may help model appropriate classroom and clinical behavior choices. With the explosion of artificial intelligence (AI) use among students, educating the nursing student population on how to appropriately utilize AI resources may be necessary.

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  •  
    This is an image of Florence Nightingale in 1870
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    Czech nursing students 2006.
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    The American student nurse Miss Lydia Monroe of Ringgold, Louisiana, in 1942.

Degrees granted

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See articles on individual degrees for variations on the exact name.

See also

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References

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  1. ^ "Student Nurse". MediLexicon International Ltd. Archived from the original on 19 April 2019. Retrieved 11 April 2021.
  2. ^ "the definition of student nurse". dictionary.com.
  3. ^ "About YSN". Yale School of Nursing. 2015.
  4. ^ "Medical News. Education of nurses". British Medical Journal. 1: 122. 14 January 1956. doi:10.1136/bmj.1.4958.121. S2CID 220179210.
  5. ^ Hookson. "History makers: nursing ambition | Edit". edit.ed.ac.uk. Retrieved 27 September 2016.
  6. ^ "Nursing". La Trobe University. 2016.
  7. ^ "About". King's College London. Retrieved 24 October 2015.
  8. ^ Florence Nightingale Museum. "Florence Nightingale". Archived from the original on 25 January 2007. Retrieved 2 February 2007.
  9. ^ "University of Glasgow - University events - Glasgow Science Festival - Schools & Community Engagement - Monumental - Rebecca Strong". www.gla.ac.uk. Retrieved 27 December 2023.
  10. ^ Patrick, John (July 1944). "Mrs. Rebecca Strong (née Thorogood), O.B.E." Glasgow Medical Journal. 142 (1): 8–11. ISSN 0367-4800. PMC 5955648.
  11. ^ "Nurses of Note. Mrs Rebecca Strong". The British Journal of Nursing (January)". The British Journal of Nursing. 3. 1924.
  12. ^ a b Anthony, Grainne (2011), ‘Distinctness of Idea and Firmness of Purpose. The Career of Eva Luckes; A Victorian Hospital Matron.’ (Unpublished Master of Arts dissertation, London Metropolitan University, 2011).
  13. ^ a b c d Rogers, Sarah (2022). 'A Maker of Matrons’? A study of Eva Lückes's influence on a generation of nurse leaders:1880–1919' (Unpublished PhD thesis, University of Huddersfield, April 2022)
  14. ^ a b McGann, Susan (1992). The battle of the nurses : a study of eight women who influenced the development of professional nursing, 1880-1930. Scutari Press. OCLC 622730846.
  15. ^ "About the school". University of Manchester. Retrieved 2 February 2007.
  16. ^ "This week / next week" (University of Manchester); 7 Oct. 1996, p. 1
  17. ^ Tierney, Alison J. (24 October 2022). "50 years since the Briggs Report | Blogs | Royal College of Nursing". The Royal College of Nursing. Retrieved 17 January 2023.
  18. ^ Bradshaw, A (2001). The Nurse Apprentice. p. 173.
  19. ^ "Nurses, Midwives and Health Visitors Act 1979".
  20. ^ Bradshaw, A (2001). The Nurse Apprentice. p. 225.
  21. ^ "University of Glasgow - Schools - School of Medicine, Dentistry & Nursing - Undergraduate Medical School - Our facilities - A Significant Medical History - 20th Century". www.gla.ac.uk. Retrieved 1 September 2022.
  22. ^ Fox, Brooke E. "Educate and Inspire: The MUSC College of Nursing". waring.library.musc.edu. Retrieved 2 April 2018.
  23. ^ Fox, Brooke E. "Educate and Inspire: The MUSC College of Nursing". waring.library.musc.edu. Retrieved 2 April 2018.
  24. ^ Cohen, Susan L. (11 January 2024), "Parsons, Louisa (1855–1916), nurse", Oxford Dictionary of National Biography, Oxford University Press, doi:10.1093/odnb/9780198614128.013.90000382493, ISBN 978-0-19-861412-8, retrieved 6 February 2024
  25. ^ "UMSON History | University of Maryland School of Nursing".
  26. ^ "History of the School of Nursing | University of Maryland School of Nursing".
  27. ^ About. Johns Hopkins Medicine; [cited 26 May 2014].
  28. ^ "History of the School of Nursing". Archived from the original on 18 April 2015.
  29. ^ a b Goldmark, Josephine (1923). Nursing and Nursing Education in the United States: Report of the Committee for the Study of Nursing Education. The Macmillan Company. ISBN 9785882308154.
  30. ^ "Timeline of Nursing". Aapacn.
  31. ^ Yoost, Barbara (2016). Fundamentals of Nursing: shout up for Collaborative Practice. Elsevier Inc. ISBN 9780323295574.
  32. ^ "Exhibit on the History of the Yale School of Nursing". Yale University. Retrieved 2 February 2007.
  33. ^ Columbia School of Nursing. "History of the Columbia School of Nursing". Archived from the original on 9 December 2006. Retrieved 2 February 2007.
  34. ^ "What Are the Different Types of Nursing Degrees?". St. Catherine University.
  35. ^ a b "Compare different qualifications". GOV.UK. 2015.
  36. ^ a b c d Gaines, Kathleen (21 February 2023). "Why Nursing School Accreditation Matters". nurse.org.
  37. ^ "Registered Nurses". College of Registered Nurses of British Columbia. Archived from the original on 15 October 2014. Retrieved 9 October 2014.
  38. ^ "Nursing Projected to Lead Employment Growth over Next Decade". Robert Wood Johnson Foundation. 28 January 2010. Retrieved 17 July 2017.
  39. ^ Smith, Katie (8 March 2012). "What type of nursing shall I study?". Nursing Times. Retrieved 19 May 2022.
  40. ^ a b Hines, Cheryl B.; Cody, Shameka L.; Eyer, Joshua C.; Coupe, Landry (1 February 2021). "An Opioid Education Program for Baccalaureate Nursing Students". Journal of Addictions Nursing. 32 (2): 88–94. doi:10.1097/JAN.0000000000000407. ISSN 1548-7148. PMID 34060759. S2CID 235267463.
  41. ^ Alexander M, Durham CF, Hooper JI, Jeffries PR, Goldman N, Kardong-Edgren S, Kesten KS, Spector N, Tagliareni E, Radtke B, Tillman C (2015). "NCSBN Simulation Guidelines for Prelicensure Nursing Programs". Journal of Nursing Regulation. 6 (3): 39–42. doi:10.1016/s2155-8256(15)30783-3. S2CID 70692711. Retrieved 27 December 2015.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  42. ^ Aronowitz, Shoshana V.; Compton, Peggy; Schmidt, Heath D. (3 August 2020). "Innovative Approaches to Educating Future Clinicians about Opioids, Pain, Addiction and Health Policy". Pain Management Nursing. 22 (1): 11–14. doi:10.1016/j.pmn.2020.07.001. PMC 9089290. PMID 32763015.
  43. ^ Cottingham, Marci D. (27 December 2018). "The missing and needed male nurse: Discursive hybridization in professional nursing texts". Gender, Work & Organization. 26 (2): 197–213. doi:10.1111/gwao.12333. hdl:11245.1/428411f7-feaa-4e9e-9d6b-ed1458ed9462. ISSN 0968-6673. S2CID 150352761.
  44. ^ Murcia, Saidy Eliana Arias; Lopez, Lucero (4 July 2016). "The experience of nurses in care for culturally diverse families: A qualitative meta-synthesis 1". Revista Latino-Americana de Enfermagem. 24: e2718. doi:10.1590/1518-8345.1052.2718. ISSN 0104-1169. PMC 4964299. PMID 27384469.
  45. ^ "American Association of Colleges of Nursing". The Essentials. 2024.
  46. ^ McClung & Schneider (2018). "The development and testing of nursing student perceptions of dishonesty scale". Nursing Education Today (61): 28–35.
  47. ^ McClung & Gaberson (2021). "Academic dishonesty among nursing students". Nurse Educator. 46 (2): 111–115.
  48. ^ Eby; et al. (2021). "Fostering ethical integrity in nursing: An ongoing examination of diverse perceptions". Teaching and Learning in Nursing (16): 36–42.
 
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