Nurse Education Today

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1 Nurse Education Today 31 (2011) Contents lists available at ScienceDirect Nurse Education Today journal homepage: Impact of the Bologna process in Bachelor nursing programmes: The Swedish case Joakim Öhlén a,, Carina Furåker a, Eva Jakobsson a, Ingrid Bergh a,b, Evelyn Hermansson a a Institute of Health Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden b School of Life Sciences, University of Skövde, Sweden article info summary Article history: Accepted 4 May 2010 Keywords: Bachelor level nursing programme The Bologna process Higher education Major subject Nursing curriculum The higher education reform in Europe known as the Bologna Process implies further harmonisation and integration of nursing programmes into the higher education system. This study explores this process in Sweden, where the development of nursing education into an undergraduate programme started in The aim of this study was to analyse characteristics of the major subject and its relationship to other subject areas, such as medical sciences and social sciences, in Bachelor level nursing programmes in Sweden following initial implementation of the Bologna process. A constructivist approach and descriptive content analysis were employed to analyse the 2008 nursing curricula and syllabi of 27 undergraduate programmes at 26 Swedish universities and university colleges. The results revealed variation in terms and concepts used for the major subject as well as its scientific foundation, demarcation between the major subject and other subjects included in the study programmes and its relationship to the profession. These variations are linked to the variety of research orientations under debate in the Scandinavian countries: Nursing Science and Caring Science; representing different knowledge domains, focus, challenges and visions for the discipline. Potential implications of basing curricula on a major subject other than Nursing Science in a Bachelor level nursing programme are highlighted Elsevier Ltd. All rights reserved. Introduction During the past three decades, the nursing education system in Western Europe has undergone a number of reforms. In the first phase, the purpose of the reforms was to create a unified European platform of solid preregistration programmes for harmonisation of nursing diplomas and nursing qualifications. The second phase focused on integrating nursing education programmes into the higher education system to improve the status of the profession and to incorporate more qualified graduates into the practice settings. This has resulted in notable differences between existing nursing education programmes as well in the structure, levels and duration of degree study, both within and between countries (Spitzer and Perrenoud, 2006b). The current European higher education reform, known as the Bologna process, aims to create convergence of higher education and opportunities for mobility, employment and collaborative research (Oliver and Sanz, 2007). In addition, this process marks the introduction of a new educational structure in three cycles: basic, undergraduate level; second, master's level; and third, doctoral level. A common system for credits has also been introduced with 60 ECTS, equivalent to one year of full-time study. As explored by Davis (2008), this has profound implications for undergraduate nursing Corresponding author. Institute of Health Care Sciences, Sahlgrenska Academy at the University of Gothenburg, P.O.Box 457, SE Gothenburg, Sweden. Tel.: ; fax: address: joakim.ohlen@gu.se (J. Öhlén). programmes by raising the educational status of registered nurses (RNs) from diploma to graduate level throughout Europe and beyond. The development of nursing in higher education in Europe is obviously moving forward and characteristics of national implementation are reported from various quarters, such as the Czech Republic (Tóthová and Sedláková, 2008), Hungary (Betlehem et al., 2009), Spain (Zabalegui and Cabrera, 2009) and the UK (Roxburgh et al., 2009). Nevertheless, the majority of European RNs are still educated to diploma level. For this reason, nursing as higher education is seen by many countries as unrealisable on account of cultural traditions as well as social and economic factors. This view is countered by the argument that anti-graduate attitudes to nursing education are not helpful in achieving a competent and knowledgeable workforce, particularly if Europe is striving to become the most competitive economy in the world. In this way, the Bologna process will probably provide the motivation to raise their nursing education to graduate level (Zabalegui et al., 2006). Nevertheless, the cost of transforming nursing into higher education will hit some countries harder than others (Davis, 2008). This situation can be contrasted with the international perspective where nursing today is recognized as a scientific discipline in its own right (Zabalegui and Cabrera, 2009) although the actual impact of an academic nursing education on the nursing workforce is not obvious in empirical terms (cf. Gerrish et al, 2003). As Thorne claims (2006), we can be sure that the challenges of tomorrow necessitate new developments in nursing curricula in order to inform practice about the complexities and diversities of future health care demands /$ see front matter 2010 Elsevier Ltd. All rights reserved. doi: /j.nedt

2 J. Öhlén et al. / Nurse Education Today 31 (2011) Although curriculum as a field of study has not played an essential role in higher education in Europe (Karseth, 2008), it has become more important today with the expansion and increased complexity of academic training. If, according to the Nordic or Germanic definition, the concept of curriculum refers to a plan laid down by the state, it is a regulatory document (syllabus). However, the term curriculum has a broader perspective, which also includes social and political values framing teaching and learning. In contrast to a traditional curriculum, the new curriculum is oriented towards a global world and the importance of student choice, and marks a shift from subject-based teaching to student-based teaching, focusing on competence and generic skills rather than knowledge or content (Ensor, 2004). According to Karseth (2008) the current attempts to develop frameworks at a European and national level fit in with an objectives-driven curriculum based on functional ideals, which may nevertheless be contextually shaped by national education systems (Zabalegui et al., 2006). Another way to conceptualise curriculum is to focus on how it is formed, i.e. a code concept. This code concept refers to what Bernstein (1983) calls collective and integrated code and concepts of horizontal and vertical reproduction processes. Collective code means that there is an established boundary between different professions and subjects. In contrast, integrated code indicates diffuse boundaries between professions and subjects and is characterised by diversity. Questions are thus raised pertaining to the content and structure of nursing curricula in the course of implementing the Bologna process at national level, and this is discerned as one critical component in the reformation of nursing education (Spitzer and Perrenoud, 2006a). The Swedish context In Sweden, the transformation of nursing education into a degree programme started with a curriculum reform in 1977 and which was implemented in 1982 (SoU, 1978:50). The government went on to formulate curriculum content, with an equal distribution between theory and practice, the major subject then being defined as nursing. The resulting components were intended to form a research-related nursing programme. Since 1993, RN training in Sweden has involved following a coherent three-year programme comprising 180 ECTS at undergraduate level with the opportunity to obtain a Bachelor's degree. This change was a result of the Swedish government's decision to follow the Sectoral Directives of the EU/EES (Council Directive, 1977) and a reform in the Swedish higher education system (SFS, 1992:1432; SFS, 1993:100) resulting in the academisation of the nursing programme. The decentralisation and deregulation of higher education after the 1993 reform regarding autonomy, pluralism and flexibility meant that each institution could decide based on a nationally regulated qualification descriptor, the content of their own nursing curriculum with regard to the disciplinary concept for a major subject as well as its content and scope. This situation is a result of the Swedish Higher Education Ordinance (SFS, 1993:100), which omitted a definition of the major subject but does include the general learning outcomes for the degree. This could be of particular significance to Swedish nursing education in the context of a dynamic Scandinavian debate on the epistemological foundation for the discipline and its relationship with the nursing profession (e.g. Hallberg, 2006; Galvin et al., 2008; Lundgren et al., 2009) as well as a disciplinary controversy between nursing science and caring science (Sarvimäki and Lutzén, 2004). As Hall (1997) describes, during the development of the discipline of nursing in Scandinavia in the latter part of the last century, a caring orientation provided the nursing discipline with arguments in favour of focusing on the core of nursing. This orientation was informed by northern American, Norwegian and Finnish nursing theorists (Hall, 1997). This has been followed by a development towards increased pluralism with a greater focus on the patient and nursing interventions. However, in Sweden there is an ongoing disciplinary debate about what constitutes the knowledge domain of nursing as it relates to undergraduate nursing education (Östlinder et al., 2009). Furthermore, such a debate raises questions related to the previously described diversity in the nursing curriculum (Furåker, 2001) framed by the qualification description for the Degree in Nursing (SFS, 1993:100). Referring to implementation of the Bologna process in Sweden in 2007, all registered nurses have a professional qualification as well as a Bachelor's degree in nursing with at least 90 ECTS in the major subject (Government bill, 2004/05:162; SFS, 1993:100). Taken together, an inquiry into the impact of the Bologna process on Swedish undergraduate nursing education is motivated particularly by the previously described disciplinary pluralism related to national decentralisation and deregulation of curriculum decisions in the 1990s and the present intended harmonisation of the European higher education system in the Bologna process. Aim The aim of this study was to analyse what characterises the major subject and its relationship to other subjects in Bachelor level nursing programmes in Sweden after the Bologna process. Specific research questions were raised and operationalised in specific indicators, as presented in Table 1. Method We chose a constructivist approach for the study with an ensuing critical stance towards knowledge as being socio-culturally bound and grounded by and through language (Burr, 1995). Knowledge is thus socially constructed and gained through interpretations. This study consists of text material from the nursing programme curricula and syllabi for 27 nursing programmes at 26 universities (Swedish universities and university colleges). Text analysis was used to analyse the material in order to investigate the different parts, contents, and meanings of the text (Hermansson, 2003). Employing a constructivist approach, we regarded curriculum documents as texts constructed in certain contexts for certain purposes as a result of interpretations, compromise solutions and negotiations between different players with an influence on local curriculum development. In January 2008, the directors of studies or programme coordinators from all Swedish nursing education programmes were contacted with a request for their curricula and syllabi. Documents from all the 27 programmes were obtained. If the major subject was not defined in the curriculum it was retrieved from the programme website or through personal contact. Some syllabi had not been ratified by the programme committees, causing us to analyse the preliminary syllabi, in which case a representative for the programme was contacted. Table 1 Operationalized indicators in relation to the research questions. Research questions Indicators Type of document How is the major subject Terms and concepts for Programme syllabi defined and named in nursing programme curricula? the major subject Definitions of the main subject What is the scientific foundation of nursing education curricula and how is the major subject demarcated from other subjects? The scope, content and structure of the main subject and other subjects in curricula Programme and course syllabi, and literature in the first course of the major subject What kind of relationship is there between the major subject and the nursing profession? The major subject's relation to nursing practice and its scope in curricula Programme and course syllabi,

3 124 J. Öhlén et al. / Nurse Education Today 31 (2011) Table 2 Overview of the major subject in the Nursing programmes (27 nursing programmes). Major subjects Number of universities Nursing 13 Nursing Science 6 Nursing/Nursing Science 1 Caring Science 4 Caring Science with focus on Nursing 1 Caring Science with specialization in Nursing 1 Caring Science Nursing 1 The information obtained from the curricula and syllabi (2 13 pages) was subjected to descriptive content analysis (Krippendorff, 2007). The analysis, based on the aim, research issues and theoretical framework was carried out using step-by-step data reduction with the specific indicators from Table 1 in focus. Different qualitative and quantitative aspects of the text were organized into categories and themes, numbers and tables. The data was re-examined and reassessed several times by the authors to obtain inter-rater-reliability. The categories within as well as between the programmes were compared. Results Descriptions of the major subject The nursing programmes' curricula documents expounded on a variety of terms and definitions used for describing the major subject (Table 2). Here, we discerned two main paradigmatic orientations: Nursing Science and Caring Science. Both orientations were characterised in some of the curricula as multidisciplinary. However, in most of the Caring Science curricula the discipline was typically described as an autonomous human science. In Nursing Science curricula the discipline was mainly described as having a multidisciplinary base with an emphasis on Social and Behavioural Science. In the latter, topics from Social and Behavioural Science were integrated into the major subject of Nursing. Medical science, however, was not mentioned in such integrations. Several of the Caring Science curricula described Caring Science as being based on its own theories, models and concepts originating in human science values. In some of the descriptions of Caring Science there was an explicit distinction between Caring Science and Nursing, where the latter was characterised as applied Caring Science or the nursing profession. Some of the Nursing Science curriculum descriptions of Nursing as the major subject included brief descriptions of professional domains and roles for the RN (e.g. assessment, evaluation, supporting, tutoring, information provision, education, research and development). Scientific foundation of the programmes and demarcation of the major subject All programmes contained Nursing Science or Caring Science and Medical Science (Fig. 1). The ECTS range for the major subject in the programmes varied between 90 and and between 30 and 67.5 for Medical Science. Over half of the programmes included Social and Behavioural Science courses for which between 7.5 and 37.5 ECTS were awarded. Social and Behavioural Science was more common in programmes where the major subject was Nursing Science compared to programmes where the major subject was Caring Science. The Nursing Science programmes included between one and four different subject areas in addition to the major subject. Five of the programmes included Public Health, which carried between 7.5 and 30 ECTS. One programme included the subject Ethics and Life Science (Fig. 1). The analysis also revealed that the same kind of content, e.g. leadership and organisation, were described differently in the curricula: either as part of the major subject, Social and Behavioural Science, or Public Health. Elective courses were found in most of the programmes, either as part of the major subject or as a choice of two or more subject courses, which carried between 7.5 and 15 ECTS (Fig. 1). Some of the electives differed in content and focus depending on whether Nursing Science or Caring Science was the major subject of the programme (Table 3). The analysis of the literature in the first course of the major subject (as described in the course syllabi) revealed 18 different orientations (range 3 12, mean 6, median 5). Some syllabi only included literature related to the core of the major subject (Nursing Science or Caring Science) while others also include literature from psychology, public health and organizational theory (Table 4). Fig. 1. Distribution of the Nursing programmes' major subject and additional subject areas.

4 J. Öhlén et al. / Nurse Education Today 31 (2011) Table 3 Examples of elective courses in Nursing Science vs Caring science oriented curricula. Nursing Science Pain and pain management Nutrition and wound care Critical care nursing Global health Caring Science History of ideas of caring The caring environment The caring encounter/relationship Caring science perspectives on humanity Table 4 Subject fields for required readings in the first course of the main subject (based on data from 23 universities, only titles listed and no page references). Subject fields for required readings Number of universities Nursing nurse focus 23 Ethics 17 Research methods 16 Nursing patient and nurse 13 Communication 10 Caring science theory 8 Nursing theory 7 Public health and health 7 Gender 7 Nursing culture 6 Psychology 5 Nursing patient focus 4 Health care pedagogics 4 History of ideas 3 Law 3 Societal perspectives 3 Family nursing 2 Organizational theory 1 The relationship between the major subject and the profession In most of the Nursing Science curricula the extent of clinical studies, in health care practice, was clearly stated. Some of these curricula referred explicitly to the EU directives regarding apportionment of theoretical and clinical studies, implying that 50% of the course consisted of clinical studies. In some of these curricula this was specified as including laboratory work, case studies, field studies and observation studies. The ECTS awarded for clinical studies in the curricula as a whole ranged between 36 and 75 (mean 49.9, median 45.5). Examination of the Nursing Science curricula revealed that 14 programmes included clinical studies in all subjects, irrespective of whether there was a combination of two, three or four subjects in the programmes. In eight of these programmes, clinical studies were only part of the major subject and in five programmes they were part of the major subject, including part of one other subject (these five programmes included three or four subjects). Hence, the apportionment of the clinical studies subject field varied in these programmes between being part of the major subject only and being part of up to four subjects, as shown in Fig. 2. In curricula in which Caring Science was the major subject, all content related to clinical studies (i.e. laboratory work, exercises, etc.) was allocated to a particular course block, which was more or less separate from the major subject. The theoretical content of the major subject (Caring Science) was thus separated from professional nursing. The opposite was apparent in the Nursing Science programmes in which all clinical studies were part of the major subject. Pedagogical profile and structure in nursing programme syllabi Six of the programme curricula specified pedagogical profiles: problem-based learning, process-oriented supervision and workintegrated learning in clinical education. In addition, pedagogical values were included, such as humanistic orientation, the belief in humans as unique, reflective and having a natural need for knowledge and skills; the human right to seek knowledge and take responsibility for personal learning and personal development; learning as a dynamic process that occurs in the interaction between teachers and students and in safeguarding the students' experiences. Four programmes highlighted pedagogical directions, such as studentactivating teaching methods, project and problem-based learning and preparation for life-long learning. The content structure of the major subject and other subjects in the programme curricula varied and could be described as a Fig. 2. Distribution of subjects and proposed clinical studies (CS) at five universities (representing the two with the least number of subjects (A and D), two with the most diversified subjects (U and X) and one medium case (P)).

5 126 J. Öhlén et al. / Nurse Education Today 31 (2011) Table 5 Curricula codes in relation to the major subject in the nursing programmes (27 nursing programmes). Nursing Science Caring Science continuum from clearly integrated code (i.e. the syllabus content is structured according to themes) to clearly collective code (i.e. syllabus content is structured according to academic subjects). In several of the Nursing Science programmes there were combinations of these two curriculum codes (Table 5). Analysis of curricula and syllabi for the Nursing Science-oriented programmes that used integrated code revealed that the course structure was related to themes (and not to scientific disciplines), such as health care and illness, the determinants of health and the necessities of human life. In contrast, an analysis of the course structure of the Caring Science-oriented programmes that used integrated code revealed that they consisted of a combination of themes and sub-disciplines of Caring Science, including the history of ideas of caring, aesthetics of caring, and the psychology of caring. Discussion Integrated code Only thematic courses (3 universities) Course structure based on matrix of subject and components (2 universities) Combination of integrated and collective codes Some disciplinary and some thematic courses (6 universities) Subject courses linked thematically, a few courses integrated more than one subject (2 universities) Mostly collective code, combined with/ integrated in clinical courses Clear demarcation of course structure in theoretical and clinical courses (2 universities) Collective code Courses labelled according to academic disciplines (9 universities) Courses labelled caring science, nursing or other subject fields (3 universities) Having employed curriculum document analysis to characterise the 27 Swedish nursing programmes following implementation of the 2007 Bologna reform (which includes the directive to omit labeling the programme's major subject) we found that universities chose curricula oriented towards either Nursing Science or Caring Science. This is not remarkable in Scandinavia, since these orientations are apparent in the different conceptualizations of the discipline and research-related to nursing in the Nordic countries. In this way, Nursing Science and Caring Science represent slightly different knowledge domains as well as focus, challenges and visions for the discipline (cf. Hallberg, 2006; Galvin et al., 2008). The curricula based on Nursing Science provide an outline of the major subject's characteristics, content and relationship to the profession in a different way to curricula based on Caring Science. We maintain that at the core of these differences is the relationship between the knowledge base of the profession and that of the major subject, as shown in Fig. 3. These differences are not categorical but appear more on a continuum with significant similarities between the knowledge base of the profession and the knowledge base of the major subject at one end of the spectrum and significant differences at the other. In terms of similarities, the major subject is formed by a professional discipline (Donaldson and Crowley, 1978) directed at knowledge development of significance to a particular field of practice, i.e. nursing (e.g. Sarvimäki, 1994). In terms of differences, the major subject appears to be formed by a theoretical discipline (Donaldson and Crowley, 1978) directed at knowledge development pertaining to particular human caring phenomena irrespective of professional practice or activities in everyday life,(e.g. Eriksson, 1997, 2001). Differences between practice and theoretical disciplines appear, for example, in new disciplinary fields which are under development. Practice disciplines develop mainly through societal factors outside the scientific community, such as academisation and professionalisation. Theoretical disciplines, on the other hand, develop mainly through internal processes in the scientific community such as specialization, differentiation or as offshoots from already established disciplines (Elzinga, 1987). Could such differences underpin the diverse conceptualisations of the major subject in the Swedish nursing curricula? These differences were most distinct in the required reading for the first course in the major subject and in the focus of the elective courses (Tables 3 and 4). Furthermore, the structuring of courses from sub-disciplines of Caring Science, such as the history of ideas of caring, is in line with the major subject as a product of internal scientific differentiation. Courses such as pain and pain management, on the other hand, are in line with the major subject as a professional discipline. A consequence of these differences is that the major subject in Swedish nursing programmes lacks common terminology and probably a common conceptualisation. Another issue related to student learning is the impact of including clinical practice in subjects other than in Nursing Science or Caring Science, as we found in 19 of the 27 programmes. This feature is new to Swedish programmes in this century (cf. Furåker, 2001). A consequence of including clinical practice in other subject courses is Fig. 3. Relationship between the major subject and the professional knowledge base as it appears in the nursing programme curricula.

6 J. Öhlén et al. / Nurse Education Today 31 (2011) that there is less apportionment of clinical practice in the major subject. This ought to be related to the fact that there was considerable variation in the total apportionment of clinical practice: from 36 to 75 ECTS. However, in the curricula and syllabi it was unclear how clinical practice in the subjects of Public Health, Medical Science, Ethical and Life Science or Social Sciences were related to the profession or what clinical expectations would be imposed on newly graduated RNs. This kind of curriculum design also raised questions about the competence of the preceptor in these clinical courses. We assume it could be difficult to find an appropriate number of RN preceptors for all students with the relevant skills and knowledge in these subjects. Inclusion of clinical practice in courses other than the major subject is closely related to what is considered to be the scientific knowledge base of the major subject. If the major subject is to be equal to the knowledge base of the profession, it would be reasonable to give it the greatest curriculum apportionment, with clinical practice integrated into most of the nursing courses. However, if the major subject only constitutes a minor part of this knowledge base, it would be reasonable to include several subjects and to include clinical practice in most of the subjects. If the latter is combined with the view of the major subject as being based on a theoretical discipline, it would also be reasonable to separate course content that is closely related to the professional sphere of nursing into special courses, as we found in a few Caring Science programmes. Considering these almost contradictory approaches, it is of some surprise to see hybrid curricula with combinations of these standpoints. After the Swedish higher education reform in 1993, nursing education programmes underwent a code change from a rational scientific curriculum code to a more humanistic and liberal educational ideal, and from an integrated to a collective code. After 2007, a switch back to a more integrated code has been in evidence. Such code shifts can of course be explained by corresponding shifts in the political and social values of society. Collective code implies that there is a clear boundary between subjects, levels and learning outcomes in curriculum and syllabi. With a collective code, it is easier for students to know what subject they are studying, to uncover the pedagogic ideology and to discover the progression between levels in the syllabi. For teachers, a collective code indicates distinct power relationships between students and teachers and between subjects. The other curriculum codes, an integrated or a combination of an integrated and a collective code, indicate boundaries between subjects, theory and practice that might not be explicit to students and teachers. Consequently, vague and abstracted curricula have an effect on the quality of nursing programmes in the sense that it is difficult for teachers, and even more so for students, to communicate and unpack unclear curricula. In this respect, teachers play an important role in making the curriculum understandable to the students. The results generally raise questions as to how the implementation of the Bologna process in Swedish nursing education has contributed to the harmonisation of a field of higher education in Europe as a whole. Can the curriculum diversities described be explained chiefly in terms of thought-provoking educational profiles, or do they also imply variable educational quality? What effect does this have on the mobility of nursing students within Europe and on the nursing workforce (cf. Davis, 2008)? Do differences in terminology reflect differences in course content and to what extent? Although these questions could be further investigated through syllabi and other course documents, we are unsure about the contributions from studies delimited to such data, given the gaps that have been revealed between educational preparation and professional demands described by newly graduated RNs (e.g. Holmström and Larsson, 2005; Danielsson and Berntsson, 2007; Schüldt Håård et al., 2008). For these reasons, we pose the empirical question: what impact do the major subjects of Nursing Science and Caring Science, and the different curriculum codes, have on the students' learning outcomes? 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