Global violence, threat of violence, and other disasters

On September 11, 2001, hijacked airplanes hit the World Trade Center towers in New York City and the Pentagon near Washington, DC. A fourth plane crashed in rural Pennsylvania. These attacks marked an end to a sense of national invulnerability and left behind feelings of uncertainty about national security as well as the impact they would have on economies of the U.S. and the global community (Jackson, 2008). A decade later, these events continue to play significantly into the current sociopolitical, economic, and cultural landscape of the nation and the word terrorism is part of our nation’s daily lexicon.

The societal reverberations of the 9/11 attacks have been many, including two immediate economic consequences: the events aggravated the economic downturn of 2001 and they shifted national spending toward security and antiterrorism strategies and away from social programs and human needs (Wiener & Tilly, 2002). Since that fateful September day there continues to be historic growth in defense spending in the U.S. and the first ever national health care reform bill was signed into law (Eisman, n.d.). The health implications from both of these consequences, along with the emergence of new infectious diseases and the aftermath of such natural disasters as the Indian Ocean tsunami in 2004, Hurricane Katrina in 2005, and the Haiti earthquake in 2010 are tremendous. In response, the health care system has focused resources on disaster and mass trauma preparedness, bioterrorism responses, and a multitude of strategies to prepare for unpredictable and diverse catastrophic events (Lewis, 2009). As a result, nurses must possess skills and knowledge in order to help create emergency response systems and work within the public health infrastructures characterized by community-wide collaboration, communication, and appropriate public policy. Nurses also need clinical knowledge related to biological agents, as well as skills to address the emotional stresses related to vulnerability and loss (Norman & Weiner, 2011).

The demographic revolution

The United States is getting more populous, older, and more racially and ethnically diverse (Institute of Medicine [IOM], 2010; Shrestha, 2006). In 2009 the older population, persons 65 years or greater, numbered 39.6 million and represented 12.9% of the U.S. population. By 2030 it is estimated there will be 72.1 million people age 65 and older and that these older Americans will represent 19.3% of the population. Additionally, by 2020 the age 85 and older population is projected to number 6.6 million, which represents a 15% increase in this age group (U.S. Department of Health & Human Services, Administration on Aging, 2010). “Population aging, especially when baby boomers reach ages 85 and older, signals a likely surge in the use of long-term care services” (Johnson, Toohey, & Wiener, 2007, p. iv). Other aging “boomers” will enter assisted living facilities or be cared for by their families and communities.

Regardless of the venue in which the aging population receives care, issues surrounding geriatric health have obvious curricular implications because educators must prepare nurses to promote health and self-care and prevent disease and disability in the large aging population. The responsibility to prepare future nurses in this manner is in keeping with a vision for health care recently proposed by the committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing (IOM, 2010). This vision calls for a system in which quality care is accessible, wellness and disease prevention is intentionally promoted, and compassionate care is provided across the life span (IOM, 2010). Not only will nursing care’s emphasis be shifted from acute to chronic illnesses, but it will increase in complexity for the ongoing management of multiple disabilities and diseases. Initiatives such as those of the Hartford Institute for Geriatric Nursing are excellent examples of bringing best practices and resources to improve the health care of older adults.

End-of-life issues also loom large for the profession. In 2000 the Robert Wood Johnson Foundation began funding the End-of-Life Nursing Education Consortium (ELNEC) administered by the American Association of Colleges of Nursing (AACN) and the City of Hope National Medical Center. To date more than 11,650 nurses and other health care professionals, representing the 50 U.S. states and 65 international countries, have received ELNEC training and are using this innovative strategy to equip the nursing workforce with needed skills and knowledge (AACN, 2010b).

The disproportionate growth of the aged population is juxtaposed to a slower growth in the working population age cohort. After its peak in the 1970s, “the growth rate of the labor force has been decreasing with each passing decade and is expected to continue to do so in the future” (Toossi, 2006, p. 19). The projected workforce shortage is also predictive of a shortage of health care providers, particularly nurses, to care for elderly patients. The declining labor workforce coupled with the second economic recession within a decade also results in fewer individuals contributing to federal and state tax resources necessary to support social programs (Buerhaus, Auerbach, & Staiger, 2009; Toossi, 2006). Additionally, soaring health costs have imposed enormous pressures on public budgets and private individuals, especially older Americans (Penner & Johnson, 2006). Collectively, these issues require difficult policy discussions relative to resource allocation. Therefore curricula should include opportunities to develop the political advocacy skills needed to influence public policy decisions relative to the allocation of resources toward health and human needs.

Another demographic phenomenon in the United States is the growth of immigrant populations. The net immigration rate, which occurs when in-migration exceeds out-migration, “will continue to be an important component of population growth in the United States through 2050” (Shrestha, 2006, p. 10). As immigration patterns change, the composition of the country (currently an Anglo-European majority) turns into a microcosm of the world’s peoples. Such racial and ethnic diversity presents policy challenges in a number of areas including assimilation, income disparities, and poverty (Shrestha, 2006). The conflict and controversy that accompany this significant demographic shift are exacerbated by the economic insecurity and volatility of our times. Multicultural diversity and ethnic understanding have major curriculum implications. Recruitment and retention of faculty and students who reflect the diversity of the population being served are also significant issues for schools of nursing.

Whether the demographic shifts include age, diversity, or other population features, there are implications for health and the resources needed to promote health. Future nurses need “the skills to influence policy formulation and the development of creative solutions to respond to changing demographics and the ageing chronically ill” (Hegarty et al., 2009, p. 5). Preparation of tomorrow’s nursing practitioners requires attention to all demographic revolutions of both developed and developing areas of the globe, including patterns of growth, migration, and ethnic or racial composition.

Technological explosion

America’s transition from a resource-based, industrial economy characterized by semiskilled factory workers and raw materials to a knowledge-based, information age economy has been reshaping society for decades. Currently, “information and communication technology (ICT) continue to change us and the world we live in” (Abbott & Coenen, 2008, para. 1) while new technological possibilities continue to revolutionize life. As a result, issues in biotechnology, genetic engineering, information management ethics, and robotics that accompany the technological progress each carry multiple implications for nursing practice and education.

Access to education and knowledge is access to wealth, which can widen the gap between the rich and the poor. Technological advancements offer “new opportunities to enhance and broaden learning experiences” (Flynn & Vredevoogd, 2010, p. 7) and prepare students who are working within complex care environments to be decision makers (IOM, 2010). As technology evolves, increased numbers of nursing programs have found that e-learning, simulation, and mobile devices offer much potential for nursing education (IOM, 2010). Web-enhanced or online learning in particular provides opportunity for practicing nurses to pursue educational programs in conjunction with busy lives (IOM, 2010; Salyers, 2005). Simulation allows students to learn and practice in a safe environment, while the use of mobile devices teaches students real-life skills (IOM, 2010). The use of technology in this manner provides educational mobility, 24/7 access to education and knowledge, and enhanced opportunities for teaching and learning or career advancement and contributes to the availability of a qualified nursing workforce (IOM, 2010).

Globalization and the rise of the global economy

National boundaries are becoming less relevant in an era of instantaneous telecommunications, free trade, and multinational corporations. The globe operates as a single worldwide production system, and the important skills are investing, strategic planning, and securing a market presence. The consequences of globalization are staggering and depend, in part, on a country’s state of development.

The health implications of globalization are both positive and negative. In the positive sense, globalization results in trade expansion, which in turn increases living standards and improves social and economic status. When the wealth of a nation improves, so does the health of the nation. Globalized knowledge exchange also allows for the spread of health knowledge regarding treatment and causes of disease between countries and health systems (Abbott & Coenen, 2008). However, advances in globalization have also served to negatively affect health. For example, adoption of unhealthy Western habits and lifestyles has resulted in increased obesity and chronic disease. Additionally, open borders and access allow for rapid transmission of infectious agents and disease (Abbott & Coenen, 2008).

Nursing curriculum should acknowledge the realities of a market-driven or demand-driven health care system based increasingly on a global economy. Curriculum should also acknowledge that health care is a significant industry whose profit margins, stock prices, and bottom lines influence salaries and employment opportunities. Curriculum should help nurses understand the influence of globalization on the transmission and treatment of disease. Nurses best prepared for changes due to economic forces understand the significance of globalization and the global economy.

Environmental challenges

Just as currency more readily crosses borders, so can environmental and epidemiological hazards. Besides health issues across the globe, there are concerns regarding sustainable development, energy availability, pollution-free water, and climate change, to name a few issues. Environmental health involves understanding how the environment influences human health and disease (National Institute of Environmental Health Sciences, 2005). It also involves an awareness of the impact that environmental conditions have on the health of individuals and populations and of interventions that can improve the impact nurses and others have on the environment and the impact the environment has on the health of the people (National Institute of Environmental Health Sciences, 2005; Shaner-McRae, McRae, & Jas, 2007).

Increasingly, Americans are becoming aware that the threats to public health and life are found in the frailty of our earth and our delicate interdependence. Therefore it is important for nurses to be aware that the environment affects our health and that actions in our professional and personal lives can and do make a difference. Nursing curricula should address the content and competencies related to environmental health as well as environmentally responsible clinical practice. Additionally, curricula should encourage and prepare nurses to factor environmental issues into the web of disease causation and to intervene to improve environmental health. The implications of global warming provide an excellent platform for students to discuss the ethics of protecting the environment as well as ways to conserve resources and make educated choices among products that are environmentally friendly.

Summary

These recurring issues from the broad sociopolitical and economic setting have current and future influence on the practice of nursing. Curriculum needs to acknowledge the possibilities and implications of global violence; demographic revolutions in number, age, and ethnic composition of populations; the technological explosion; the globalization of the economy and health; and the increasing awareness of environmental fragility.

Affordability

The concern for affordability, noted as early as 1947, persists today as economic and societal factors promote an increased value of a college degree in labor markets. Higher education is considered an avenue to a livable wage or to a salary to support a middle-class lifestyle. Higher education is also associated with better health and positive effects on civic engagement, including voting (Brock, 2010).

Today, higher education faces many challenges due to the current economic situation, increasing student enrollment, and rising expectations for quality and equity (Flynn & Vredevoogd, 2010; Heyneman, 2006). Cuts in federal and state funding have affected publicly funded institutions while fluctuations in the stock market have contributed to the declining value of endowments. In short, higher education “will be asked to do more with less” (Flynn & Vredevoogd, 2010, p. 6).

Because of societal concern for a living wage, the financing of higher education becomes a crucial public policy debate. Within that debate, the academy should prepare persuasive arguments for the merits of education beyond salary, society’s obligation to invest in human infrastructure, and the importance of public commitment to higher education. The specific charge for schools of nursing is to articulate the cost-effective contribution that nursing makes to the improvement of the health of the nation.

Access

Another issue with historical roots that persists today is access to higher education. The issue of access is important considering society’s transformation from an industrial economy to an information-based, global economy because college graduates have “substantially better prospects in the labor market than peers who stop their formal education after high school” (Brock, 2010, p. 110). While access to higher education has increased substantially for women, Hispanics, Asians, and Pacific Islanders, other racial and ethnic groups, such as American Indians and Alaskan Natives, remain underrepresented (Brock, 2010).

In the twenty-first century all Americans must be provided with the “skills they need to succeed in the global economy and lead satisfying, productive lives. Our people and our nation will be poorer and weaker if we fail to provide real opportunities for all Americans to fulfill their potential and succeed in higher education” (National Commission on Accountability in Higher Education, 2005, p. 6). The ability of more Americans to take advantage of the multiple benefits and opportunities that higher education affords requires public policies and political will that support access as well as higher education institutions that make real those opportunities. As administrators of nursing schools pursue robust enrollments of diverse and talented students, affordability and access are crucial considerations for the profession.

Accountability

Worldwide, governments and taxpaying publics are questioning the allocation of scarce public resources. The concept of high-quality, affordable public education is threatened by the competition for funding of other public needs. This, along with rising fear about the deterioration of the U.S. higher education system, low completion rates, and poor preparation of a workforce ready and able to compete in a global marketplace, led to the formation of the Spelling Commission. The purpose of this commission was to recommend a national strategy for postsecondary education reform, with an emphasis on “how well colleges and universities are preparing students for the 21st century workforce” (Floyd & Vredevoogd, 2010, p. 19).

Several forces prompt this increased accountability for higher education. In times of cost cutting and corporate downsizing, business and private sector management looks to education, and its products, for competitive strategies. Also, drastic state budget cuts have caused policy makers and taxpayers to require justification for higher education funding. Legislatures have tended to disallow tuition hikes and request internal moves toward efficiency. Additionally, “publicly funded institutions must be accountable to their principal stakeholder—the public” (Floyd & Vredevoogd, 2010, p. 10). Each of these forces promotes increased public scrutiny and higher expectations.

Accountability, therefore, becomes a multidirectional force. Institutions of higher education depend on the government for funding and are therefore highly accountable to the public for academic productivity and fiscal prudence. Schools of nursing are accountable to state legislatures, Congress, and the public regarding the preparation of adequate numbers of competent nurses. Governments, in response to their perceived accountability to the public, act to regulate and reform higher education. Accountability will continue as a significant theme in higher education.