A COMPARATIVE ANALYSIS OF NURSING EDUCATION AND OTHER FORMS OF EDUCATION IN NIGERIA: IMPLICATIONS FOR GLOBAL STANDARDS TO PROMOTE INTERNATIONAL COLLABORATION AND ADVANCED ENTRY LEVEL COMPETENCY OF NURSES

The purpose of this paper was to highlight points that are necessary to bridge the gaps, where they exist, in relation to the structures, process and outcome of nursing education when compared with those of other professions. As a profession, nursing is broad in scope, and nurse practitioners are expected to possess a body of knowledge and skills for dependent, independent and inter-dependent practice. In many professions, preparation usually takes place in Colleges or University settings and educational preparation is usually prolonged to include instructions in the specialized body of knowledge and techniques of the profession. However, nursing education globally is highly variable, taking place in a myriad of programmes at the hospitals, technical institutes and institutions of higher learning with no uniformity. Furthermore, regarding educational outcome, many nurses in recent years are unable to meet the entry level competencies for registered nurses/midwives prior to employment into full practice. In other Medical Professions, including Medical Doctors, Medical Laboratory Scientists and Radiologists, a period of internship is provided for mastering of skills to enhance efficient and effective practice. This should also assist newly qualified nurses to improve on their entry level competencies to promote efficiency in their practical performance. It is therefore recommended that the regulating bodies should set standards of nursing education that are globally uniform and enforce compliance with such standards including admission criteria, contents/components; teachers’ qualification/certification and teaching facilities including materials and equipments. Furthermore, the recent plans to integrate Internship Programme into the training plan of graduate nurses is a step in the right direction and should be implemented without further delay to take nursing education and practice to greater heights.


INTRODUCTION
As a dynamic service oriented profession, nursing has metamorphosed from the primitive and degrading master/ servant practice relationship to the era where nurses are leading health care innovations. Although the pace of development is slow with a lot of hiccups, growth is a needed ingredient if nursing should meet the health needs of the society. Nurses form the majority of health care providers all over the world and remain the only professionals who are always with the patients on a-24-hours basis. Whether in the critical care setting or in a more relaxed arena for palliative care, the nurse is not only expected to be there always, but should possess the knowledge, skills and the right attitude to provide the needed care effectively and efficiently. This is where the role of nursing education should remain critical.
It is often said that one cannot give what he/she does not have. Similarly, there is also an 1 I. I. Akpabio, Department of Nursing Science, College of Medical Sciences, University of Calabar, Cross River State, Nigeria.
adage of "Garbage in and garbage out." For nursing education to achieve the expected goal of quality assurance in the health sector and take nursing to greater heights as a profession there should be constant reviews of the structures, process and outcome in relation to the goals of nursing education like what is obtainable in other professions. It is by so doing that mountains could be levelled and valleys filled wherever possible, so as to get a level ground for performance. This paper will not attempt to review other forms of education outside the nursing profession but will only highlight some of the points that are necessary to bridge the gaps, where they exist, in relation to the structures, process and outcome of nursing education.

THE MEANING OF EDUCATION
The Oxford Advanced Learner's Dictionary defines education as a process of teaching, training and learning, especially in schools and colleges to improve knowledge and skills (Hornsby, 2001). Although not included in the definition, the aim of education is for practice. As a process, education must be ongoing moving from one step to another. It can therefore never remain static. This indicates that education should progress from one step to another to meet the ever changing needs of the society. Thus whether it is the general educational setting or in the nursing profession, education is expected to be progressive, ongoing and growing from one stage to another or from the lower level of the discipline to the higher or next level.
Teaching, training and learning are used interchangeably. However to teach specifically, means giving lessons to students or giving information on what should be known, while training involves the teaching of skills for a particular job or activity. Furthermore, learning means to gain knowledge or skills through experience or being taught. The teaching, training and learning activities are all involved in nursing education as well as other forms of education. However some parts of the teaching arena, the content of what is taught, the process of providing the knowledge and skills and the outcome expectations could sometimes be similar or different.
In both nursing and other forms of education, the methods or criteria for evaluating structures, process and educational outcomes are different, with the need to be more flexible in the general educational sector than that expected in nursing. This is necessary since the goals of nursing includes activities to promote health, prevent illness, restore health and alleviates suffering. The emphasis is therefore on maintaining health and saving lives rather than being profit oriented. On the other hand, other forms of education settle for providing knowledge, improving skills and attitudes to enhance economic profit.
In a more general perspective, nursing education shares many similar characteristics with other forms of education. A nurse is expected acquire knowledge, skills and attitudes relevant for dependent, independent and interdependent practice both at the individual and group basis. Thus in all, the structures, process and educational outcome should meet the needs of the learners and bring the output that meets the societal needs.

HISTORICAL PERSPECTIVE OF NURSING EDUCATION AND OTHER FORMS OF EDUCATION.
Historically, nursing education shares a lot of similar characteristics with that of nursing profession globally, developing from the precolonial era through the colonial to the present age of technological advancement. Furthermore, it could be argued that nursing education has been influenced over time by religious, political, socio-economic and scientific factors of the time.

The pre-colonial and colonial era
According to Etifit (2008), at the precolonial era, the care given to the sick was primitive, pre meditated and unscientific, based on superstition, cultural and religious beliefs and values, women's roles and status, war as well as societal attitudes. Traditional female roles of wife, mother, daughter and sister have always included the care and nurturing of other family members. Thus nursing education and practice was dominated by traditional nursing roles. Religion also played a significant role in the training of nurses.
Furthermore, Berman et al (2008) documented the historical perspective of nursing education and practice to have covered the crusades that brought about the formation of several orders of knights, including the knight of Saint John of Jerusalem, the Teutonic knights and the knights of Saint Lazarus. These brothers provided nursing care to their sick and injured comrades, built hospitals, the organization and management of which set standards for the administration of hospitals at that time.
Society's attitude about nurses and nursing also significantly influenced professional nursing practice. Before the mid 1800, nursing according to Berman et al (2008) was without organization, education or social status unlike what was obtainable in the medical profession. According to Brown (2002); Partridge and Eric (1966); physicians in the narrow sense (Specialists physicians or internists) are commonly members or fellows of professional organizations. These include American College of Physicians or the Royal College of Physicians in the United Kingdom and such hard-won membership had remained a mark of status.
The prevailing attitude, which influenced nursing, was that a woman's place was in the home and that no respectable woman should have a career. The role for the middle class woman was that of a wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband, a responsible mother to her children and a kind care giver to the sick. Nurses in the hospital during this period were poorly educated; some were even incarcerated as criminals.
Another image that existed in the early 19 th century that had affected nursing education and subsequent generation of nurses was the image of nurses as doctors' handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic and when the medical profession portrayed increasing use of scientific knowledge that at that time was viewed as a male domain. Since that time, several images of nursing have been portrayed. The heroin image evolved from nurses' act of bravery in World War 2. Other images in the late 1900s included the nurses as sex objects, surrogate mother, tyrannical mother and body expert.
Furthermore, Berman et al (2008) asserted that Florence Nightingale's greatest achievement has remained her contributions to nursing education. She was recognised as nursing's first scientist theorist for her work "Notes on nursing, what it is, and what it is not," . She founded the Nightingale Training School in 1860. Her graduates travelled from there to other countries to manage hospitals and institute nurse training programmes. Nightingale's vision of nursing, which included public health and health promotion roles for nurses, had its focus on developing the training of nurses within the hospitals. This heralded the shift of nursing education from homes to institutions within the hospitals. This historical perspective has shown the humble origin of nursing education which dominated for centuries as against other forms of education. For instance in medical education, their training had remained regulated in institutions of higher learning with requirement for prior educational attainment before education and registration of doctors following educational qualifications (Brown, 2002;Fildes, 1949). Till date, many have refused to accept the place of nursing education within the institutions of higher learning and not only as an art but also in the domain of science.
The trend in Nigeria was similar to that in other parts of the world. Missionaries arrived Nigeria in the early 19 th century (1850-1900), preached the gospel, administered to the sick, wounded and orphaned children, established hospitals and mission posts in various parts of the countries. These later became the training schools for nurses and midwives under them as hospital-based and apprenticeship system. In all, training had remained un-regulated with no specific requirement for educational attainment and registration of nurses.

Nursing education in the age of technological advancement
Nursing education has evolved through series of reviews to attain better standards in response to societal needs and in line with other medical and allied medical sciences. For instance, according to Miley (2012), Radiologic Technology, in line with nursing had come a long way from the discovery of X-rays to radiation therapy and nuclear medicine. Technicians have had to evolve along with the technology with many skills that contribute to successful patient diagnosis and treatment.
An understanding of contemporary nursing education and practice include a look at the definition of nursing, recipients of nursing, scope of nursing practice, setting for nursing practice and education, nurse practice acts and current standards of nursing education and clinical practice. American Nurses Association (2003) gave the most current definition of professional nursing as the protection, promotion and optimization of health and ability, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals,

A COMPARATIVE ANALYSIS OF NURSING EDUCATION AND OTHER FORMS
families, communities, and population.
This definition clearly identifies nursing as broad in scope, with the unique requirement of processing a body of knowledge for such practice at a dependent, independent and interdependent setting. This requirement gives a view of nursing as a profession. Thus nursing has been identified as the oldest of the arts and the youngest of the professions (Basavanthappa, 2004) when compared with other disciplines in the health sector.
Nursing when viewed as a profession is unique because it addresses the responses of the individual and families to actual or potential health problems in the humanistic holistic manner. Nurses now have many roles such as care-takers, decision-makers, advocates, teachers, change agents, counsellors and managers, and they often assume several roles at the same time in a dimension that might not be imagined in other disciplines. Nursing education therefore needs to provide the practitioners with adequate preparation to meet the emerging challenges as complete professionals. Emphasis therefore is that apart from knowledge, education must touch on attitudes of being professionals with ability for expanding scope of practice.
Professional preparations usually take place in a college or university setting. Preparation is usually prolonged in order to include instructions in the specialised body of knowledge and techniques of the profession. Professional preparations include more than knowledge and skills, but also an orientation to the beliefs, values and attitudes expected of the members of the profession. However nursing education around the world is highly variable, taking place in a myriad of programmes at the hospitals, technical institutes and institutions of higher learning, with the need to initiate the development of global standards for basic nursing and midwifery education.
Maintaining global standard in nursing and midwifery education require the utilization of a theoretical model to guide quality teaching, training and learning experience. The appropriate model based on holistic approach to health care could involve the three-quality dimension theoretical model introduced by Donabedien, which stresses or emphasizes on structures, process and outcome. Thus with nursing education as well as other forms of education, good structures are required to enhance good process, while good process increases the likelihood of good educational outcome.

Educational structure
In Donabedien's model of quality education, structures describe the physical characteristics in terms of size, equipments, personnel (the supply of nursing staff, the skills level of the nursing staff and the overall quality education/certification of nursing staff and the location of the teaching, training or learning. In the nursing sectors of many countries, majority of teaching, training and learning activities are still under the schools of nursing, which at the moment have not attained the status of colleges. Similarly, majority of the teaching staff in the various schools of nursing are yet to obtain higher level of education/certification as graduate nurse teachers as it is with other forms of education.
Over the decades, organizations and governments have developed statements, regulations and standards for nursing practice and education, but these are yet to be implemented. A greater part of nursing education is still being provided at the technical level in the schools of nursing. Furthermore, despite the need for nursing education to shift into the universities as it is with other professions, till date, there are still minimal or negligible numbers of universities offering Bachelor degrees and the situation is worse with the post-graduate programmes. The consequence of this is that majority of nurses who need to advance further academically deviate to other disciplines to obtain post-graduate degrees, unlike what is obtained in the other profession where post-graduate education is obtainable in the relevant discipline. Thus the broad field of nursing is left narrow and undeveloped. Furthermore, attempts aimed at providing the professional education needed to achieve the broad scope of practices expected of nursing and also provide adequate numbers of graduate nurses to meet the manpower need of this calibre of staff result in minimal impact. It is clearly a fact to state that specialization in any discipline could be achieved at the post-graduate levels of education.

Educational process
Process is concerned with the methods on how the teaching, training and learning are achieved. It is concerned with the relevance of education to students' educational needs, whether the education is appropriate, complete and timely. It focuses on the manner in which knowledge, skills and attitudes are influenced, including the principles that guide such learning experience. Nursing is very much involved with the client or patient as a person and thinks in terms of the Bio-psychosocial paradigm with the aim of strengthening the clients' optimum health, response to illness, trauma or treatment. Nurses have a responsibility to provide optimum levels of satisfaction and safety in the care they give to their patients.
Nursing education should prepare the nurse to render professional nursing care to persons of all ages, in all phases of health and illnesses in a variety of settings. This is necessary to produce well qualified and complete professional nurses. Hence nursing education should not only be at the advanced level of graduate programme, but should be guided always by regularly reviewed educational plans and conceptual frame-work. At the moment, teaching and learning at the various schools of nursing do not reflect current and emerging trends in adult learning. For instance how many schools of nursing especially in the developing nations are properly utilizing information communication technology, projectors and relevant visual aids to meet the trends of modernization with learning? How many schools of nursing have properly developed the concept of learning that involves extensive review of literature, independent learning and extensive use of seminar presentations by students?
It could be observed also that academic progression through nursing programmes is still slow, and teaching/ learning in various schools of nursing does not include inter-professional learning opportunities that could promote collaboration in practice. In the area of standards, the nursing and midwifery council of all the countries including Nigeria have been vested, and is performing the responsibilities for ensuring high standards of nursing education and practice. However, according to McLaughlin (2007) there are no global standards of nursing education. Each region, country and state set their standards of nursing education.
If nursing practice, which is influenced by nursing education, is expected to be efficient, safe and meet clients' satisfaction globally, then the standards of nursing education should be globally in uniformity in the areas including admission criteria, development requirement, agreeable extent of content components, nursing and midwifery faculty requirements, nursing and midwifery programme graduate qualification as proposed by McLaughlin (2007).

Educational Outcome
Educational outcome focuses on the most demonstrable changes in knowledge, skills and attitude to enhance efficient and effective practice. Much of the educational outcome observed in the arena is still in the area of curative care. The output of nursing education is not reflected in the promotion of collaborative practice and community mobilization for health promotion activities. Additionally, the competency levels of clinical nursing practice among qualifying students are yet to reach satisfactory levels. Many are still unable to meet the entry level competencies for registered nurses/ midwives, and these issues should receive prominence in future deliberations aimed at improving standards in nursing practice.
Another dimension where the outcome of nursing education outcome could be facing challenges is in the implementation of the nursing process by trained nurses to promote independent practice. Nursing process has been identified over the years as a necessary tool for nursing practice and has been included in the curriculum of schools and departments of nursing. However students' understanding including internalization of the concepts are still questionable since the practical aspect of the nursing process is yet to receive the attention as had hitherto been expected in the practice arena. Nursing process requires the nurse to carry out assessment of the client's health condition, identify actual and potential nursing problems, make appropriate nursing diagnosis based on assessment made, plan for the care with the clients and significant others, implement the plans and evaluate outcome of care following the implementation.
Till date, nursing process as a tool of care is yet to take off in many health institutions and where attempts are made at implementation; the practice is far below the level that should be expected. One reason for this abnormal situation may not be far from the poor attitude of many

A COMPARATIVE ANALYSIS OF NURSING EDUCATION AND OTHER FORMS
nurses who believe that the duty of a nurse is only to carry out doctors' orders. Such beliefs are still very much in existence till date as a result of the humble beginning of nursing training earlier documented under the historical perspective of nursing education.
With the other professions, the dependent, interdependent and independent roles are well recognised and practiced. However, the image of a nurse as the doctor's handmaiden is still dominating and influencing outcome of nursing education in many sectors and countries. It should be stated that if any of the three expected roles is missing, then nursing practice is not complete and will therefore be ineffective and inefficient.

BRIDGING THE GAPS IN NURSING EDUCATION
 The current entry qualification into the schools and departments of nursing is commendable and must be maintained.
Nurse leaders should at all times ensure adherence to the standards and resist pressure from both within and outside the health sectors to make nursing a dumping group for non-qualified candidates. Nursing is advancing from the era where education involved teaching of skills to women at homes and hospitals to enable them care for the sick. To take her rightful place in the society, just like other professions, nursing has gone scientific and only the best is adequate to give the care that could meet the current societal needs.
 Nursing education should be broad based covering course in the sciences, humanities, arts etc. so as to provide the learners with adequate abilities: knowledge, skills and attitudes necessary to render holistic care that meet the biopsychosocial needs of clients of all ages and at all settings.  It is necessary to set standards of professional education and practice to be uniform globally. For this reason, Nursing Associations and other nursing regulating bodies should work together through an umbrella, such as International Council of Nurses (ICN) to set universal standards in nursing education. This will promote exchange programme between countries, improve collaboration and expose nurses to advanced nursing practice.
 The recent plans to integrate internship programme into the training plan of graduate nurses is a step in the right direction and should therefore be implemented without further delay. Internship programme for new graduate nurses should go a long way in improving their entry level competencies.
 Nurses should continue to promote lifelong learning and remain self-directed. Furthermore employers of nurses should be more co-operative in providing study fellowship to nurses who are ready to further their education in the field of nursing and assist them financially to attend conferences.
 Education of nurses, both at the formal and informal levels should include exposure to information communication and technology skills, which could assist their educational development through internet. Promoting such exposure also requires the provision of internet facilities, which should be available at all times. Finally, nurse managers should regularly carry out evaluation or inspection of educational institutions to assess compliance with standards of nursing education including admission criteria, programme development criteria, contents/components of the curricula, teachers' qualifications / certification, teaching facilities as well as materials and equipments, which should be updated regularly to meet teaching and learning needs.

SUMMARY AND CONCLUSION
This paper has highlighted the meaning of education with specific emphasis on nursing education, comparing and contrasting some aspects of it with other forms of education. Historically, nursing education, unlike other forms of education had a very humble beginning, from training of women at homes and after wards at the hospitals to provide care to the sick and injured. Till date, many still see professional nurses as doctors' handmaiden. For instance, the nursing process has not received the expected prominence since its inception some years back. The excuse has always been: "No time to implement nursing process due to busy schedules." This attitude has contributed in eroding the independent roles of practicing nurses.
Furthermore, in both nursing and other forms of education, the methods or criteria for evaluating structures, process and educational outcome could be different, with the need to be more flexible in other educational sectors than that expected in the nursing arena. This could be necessary since the emphasis in nursing is to promote health, prevent illness, restore health and alleviate suffering rather than being profit oriented.
Additionally nursing has been identified as the oldest of the arts and the youngest of the professions. Nursing education around the world is still highly variable, taking place in a myriad of programmes at the hospitals, technical institutes and institutions of higher learning. To be truly professional, nursing education should be shifted into institutions of higher learning with nurses especially at the post-graduate level being educated in the discipline of nursing as it is with other professions. It is also necessary to set standards of professional education to be uniform to an appreciable extent globally so as o promote exchange programmes between countries, improve collaboration and expose nurses especially in the less developed nations to more advanced nursing practice.