GUIDELINES FOR THE PREPARATION OF NURSE EDUCATORS OR HEALTH PROFESSIONAL

The move of nursing education to higher education is regarded as one of the most transformative achievements in nursing in South Africa. In South Africa, as in countries across the globe, nursing is faced with human resource challenges. Such challenges are not limited to nurse shortages but to a shortage of nurse educators which is anticipated to be further impacted by the high number of nurse educators who are close to retirement. The shortage of nurses in the country therefore necessitated an increase in the recruitment of potential nurses, and a concomitant increase in the number of nurse educators to prepare these nurses. A team elected by the Forum for University Nursing Deans in South Africa (FUNDISA) was tasked firstly to explore the relevance and quality of the preparation of nurse educators before attending to the up-scaling of production of nurse educators. The task team conducted a survey amongst newly-qualified educators, heads of Nursing Education Institutions (NEIs) employing newly-qualified educators, and heads of nursing schools in Higher Education Institutions (HEIs) which prepare nurse educators. A workshop was also conducted at a FUNDISA business meeting to analyse current nursing education programmes within HEIs. Many gaps were identified across the nursing education programmes offered and recommendations for improvement were made by participants. The Task Team then met to develop guidelines for educators of health professionals based on the survey and workshop input. The guidelines developed by the task team include requirements for entry to the programme; the prescribed body of knowledge for health professional education including theoretical foundation of Health Professional Education, curriculum development, didactics, clinical teaching and learning, management of health professional education and the history and contemporary issues related to nursing education; practical requirements; level descriptors and a range competencies.

schools in Higher Education Institutions (HEIs) which prepare nurse educators.The Project Team presented the results of the survey to the FUNDISA Business Meeting of 1 st September 2011 at the University of Fort Hare, where a workshop was conducted which analysed current nursing education programmes, identified major problems and made recommendations for improvement.The Task Team met again and developed guidelines based on the workshop input.It was decided that the term "Health Professional Education" should be used so as to make it inclusive for other Health professions who might want to use the educational programmes.
In many countries (Australia, Ireland, UK) nursing education moved out of hospital schools into higher education within the last ten to 30 years, and this has exacerbated the debate.Mannix et al (2009, p.60) summarizes the Australian situation as follows: "While …the majority of graduates transition successfully into the nursing workforce and meet the expectations of managers in the clinical setting, from an education and health sector perspective, there is still significant concern about the clinical learning and teaching components of undergraduate nurse education" .One of the questions raised is whether the new curriculum approach with increased humanities addresses the "real work" of the nurse (Furaker, 2009).However, there is general agreement on the following points: 1.When hospitals lost the hospital-based nursing schools they lost the students as a workforce, but they also lost the nurse educators who managed the nursing education taking place in the hospitals.This left the hospitals "without an important leadership layer" (Mannix et al, 2009, p. 61)."These nurse tutors has represented a strong and direct link between hospital administration and students and were integral to maintaining the clinical setting as a learning environment, as well as a site of healing and health care" (p.61).2. Having a dual system involved (health and education) has "engendered barriers between those who teach the classroom components and those who engage with students in the clinical practice environment" (Mannix et al, 2009, p.61).This is an increasing reality in the South African system.3. The health system is challenged by acute and chronic shortage of experienced nurses, leading to higher expectations of new graduates as well as limited exposure to role models in the clinical areas (Mannix et al, 2009).The outflow of professional and specialist nurses from South African over the last 20 years was felt in all sectors of the health system.4. Clinical training devolved to practicing nurses as "clinical teaching divisions" within hospitals were closed and nurses redeployed to care units.Practicing nurses have found it difficult to accommodate the teaching component of their roles.They are often burdened by high clinical workloads, and have not been prepared to facilitate student learning.However, this model allows for authentic socialization into the world of the nurse (Mannix et al, 2009;Hackmann, 2007;Myall et al, 2008). 5. Clinical areas have, over the last thirty years, become more complex due to higher acuity levels, greater treatment sophistication and shorter care periods.This often leads to over-crowded and under-resourced clinical areas, which is short on the goodwill and commitment to teaching students (Mannix, et al, 2009).6. Clinical areas can only cope with a limited number of students at any one time.This situation is complicated by the fact that the academic calendar limits the times during which students can be placed in clinical areas and may lead to rivalry and centralization, which denies schools the most appropriate placements.Any call to increase clinical time immediately raises the question of where the students will be placed for these additional hours (Mannix et al, 2009;Kline & Hodges, 2006).In South Africa this problem is complicated by the fact that University nursing students have to compete with nurses from colleges, who are employed by the Department of Health and are therefore seen as the priority students by the system.7. Students find some clinical placements stressful, have to travel long distances to some of them, and have to work in unfamiliar situations most of the time.While students and nurse academics think these placements are important, it is not an easy part of their training (Ashford Lawrence, 2010;Mannix et al, 2009).In South African many schools implemented community-based or community oriented nursing programmes, increasing cost and stress (Mtshali, 2009).8. Problems with clinical preceptors are many: It is difficult to find them in adequate numbers when large cohorts of students have to be accommodated, they often have limited preparation in teaching, and limited knowledge of the curriculum.Students sometimes experience repeated change of preceptors and clinical preceptors might not be familiar with all the clinical areas (Happel, 2009;Hossein et al, 2010).In South Africa these teachers have been absent in most cases over the last 20 years, and has only re-emerged recently (see chapter 6).9.If students are placed in many different health settings for their clinical training, they enter each setting as strangers, and need some time to become oriented before they can start learning.At the same time, this allows for richer learning in diverse clinical settings (Mannix et al, 2009).
As it is seen in its predecessors, while sharing many of these international changes, South African nursing education also experienced some unique changes.A new national policy which resulted from the De Lange commission for nursing education was that nursing education should move into post secondary education institutions, and professional nurse training done only in formal colleges and universities.Since the late 1980's the SA Nursing Council regulated that all professional programmes (leading to registration as a nurse or midwife or a specialist) had to be offered by a nursing college in partnership with a nursing department at a university.This was a move away from "hospital-based schools" for at least a sector of the nursing education programmes which led to new relationships having to be built, and formal affiliation agreements having to be made (Mashaba 1995: 128).In the 1990's colleges were consolidated, creating very large entities, often with multiple campuses and offering a very wide spectrum of programmes.In some provinces this meant only one College was left, with up to 24 teaching sites across the province.As the country implemented a National Qualifications Framework to standardize qualifications, and the South African Qualifications Authority had to approve all qualifications according to new rules, administrative and educational demands increased.In combination with the NQF, the promulgation of the Higher Education Act No 101 of 1997, as amended, created a new higher education landscape, The NQF levels in higher education range from level five to ten and again nursing education had to adapt.
It is therefore very timeous to review the educational preparation of nurse educators in this country to be in line with current expectations.

Assumptions of the guidelines
After the educator of health professionals has achieved an educational qualification, one year of formal mentoring is essential to achieve a well-rounded, competent educator.Although a programme preparing nurse educators might well include nursing research modules and projects, the research component is not the focus of this document, and is therefore not addressed.

The body of knowledge constituting nursing or health professional education
In reviewing the current Nursing Education Programmes, it was found that there was little congruence between what different Nursing Schools perceive as essential content areas in such programmes and what the different content areas are called.The following content areas, seen as constituting the field of health professional education, are briefly described below.NEIs are urged to choose titles for the modules in the Nursing Education qualifications which accurately describe the content.
The number of credits for each content area will not be addressed, since programmes may differ with regard to the number of credits they contain.However, the weight of the components is indicated after each title, with a total of 9 in all.This means that if a programme consists of 120 credits and comprises only nursing education modules, then the module(s) covering the content "Theoretical foundation of Health Professional Education" will have 13 credits and the module(s) covering the content under "Curriculum development" will have 26 credits.

History and contemporary issues (1)
The history of health professional education nationally and internationally Comparative health professional education Contemporary issues nationally and internationally Profession-specific content will also be included

Minimum electronic competencies required from educators
It was found that the level of competency required from nurse educators in different educational institutions differs widely.To allow educators to work with the current and future generations of students, and to use modern electronic media in their teaching and assessment creatively, the following electronic competencies are deemed essential:  Computer competence, with regard to at least word processing and Internet searching;  The ability to use at least one social network medium in the teaching/learning process;  Being competent to use an electronic student information system;  The ability to utilize an electronic teaching/learning management system in order to offer a module, e.g.: "efundi", "click-up", "e-learning", "moodle".

Practical exposure of students in nursing education programmes
Most recently qualified nurse educators and their supervisors indicated a need for more practical exposure and the opportunity to practise teaching skills during the educational programmes that prepare nurse educators.The following minimum exposure is suggested (for other health professions the educators will be attached to HEIs offering programmes in their own professions):  A 10-day attachment to a senior nursing education mentor.
During this time the student has to:  Prepare for and conduct a teaching session every day with at least three sessions each in a classroom, simulation laboratory and clinical setting;  Prepare, conduct and manage assessment in each of the three settings;  Record data in the electronic student information system.
 A 5-day attachment to a Nursing Education Institution manager.This attachment does not refer specifically to the Head of the Institution, but to a person managing aspects of the functioning of the Educational Institution.
During this time the student has to be exposed to the NEIs:  Interaction with the process of regulation of students e.g.: SANC, SAQA, CHE;  Quality improvement processes;  HR management;  Financial management;

 Projects
These should include at least the following:  Designing and developing a curriculum (group project);  Developing a course outline with an annotated bibliography based on an electronic resources search (individual project);  Setting up a course on an electronic teaching and learning management system.

In-service needs of current nurse educators
Based on the weaknesses identified by recently trained nurse educators and their supervisors, as well as developments in the field, the following in-service needs for current nurse educators practising in NEIs were identified:

Educational programmes to prepare nurse educators or health professional educators
It is recommended that all nurse educators be prepared at the level of a Post-Graduate Diploma (PGD).If a person wants to specialize in Nursing Education at Master's level, s/he should first complete a PGD towards registration as a Nurse Educator, and then a research Master's degree focusing on a nursing education topic.

Entry level nurse educators
The entry requirements for a PGD in Nursing Education should be:  A Bachelor's degree;  The community service year and one year's working experience in nursing.
Nurses who were prepared at Diploma level have to access the PGD by successfully completing a defined number of module examinations.These examinations may be "challenged", meaning that candidates will be allowed write the examination without attending the module or course, and only register for such a module or course if they fail the challenge examination.If they pass the examinations, they have direct entry into the PGD, but if they do not, they have to take the required modules for "non-degree purposes" before they can gain access to the PGD.
The required modules for any clinical PGD are:  Anatomy and Physiology  Pharmacology For all PGDs, including the Nursing Education PGD, the challenge modules are:  Research  Academic literacy (which includes academic writing) and literature searches.

Promotion to senior level nurse educators
To be able to gain entry into a more senior position as a nurse educator, the nurse will have to complete a qualification in the specialization s/he wants to teach or is teaching.This might be a PGD in Advanced Midwifery for a person teaching Midwifery, or a PGD in Critical Care for a person teaching general nursing.

Competencies of the nurse educator
The South African Nursing Council (SANC) initiated a discussion in 2011 about the competencies of a nurse educator.Based on a document review, FUNDISA suggested a list of required competencies.This list provided the basis for the survey, and can be used as a point of focus for the development of curricula for programmes preparing nurse educators.
Competence concerns the ability to deliver a specified professional service, referring to the total role functioning of the professional, and incorporating a number of units of competence (Christie, 1995;Ashworth & Saxton, 1990).Competence describes the expected outcomes of a particular work role and acts as a benchmark against which individual performance is judged.A unit of competence (a competency) is a relatively self-contained achievement and should, as far as possible, be complete in itself.
A task is a set of activities aimed at reaching a specific goal or objective and involves a number of skills.It exists at a lower level than a competency, since it stipulates what is done, but not why something is done.The following examples illustrate the terms described above: a skill is to take a patient's blood pressure; a task is to take the vital signs of a patient, while a competency concerns assessing the current health status of the patient (Benner, 1982).While the competencies identified for a nurse educator might apply to all health professions, these competencies will have to be reviewed by the other health professions, if there is need for such skills when preparing educators for other professions.

Level descriptors
Since the preparation of the nurse educator represents level eight of the National Qualifications Framework (NQF), the following level descriptors have to be borne in mind in the development of educational programmes for this category of nurse.These level descriptors are:  To evaluate the knowledge and processes of knowledge production;  Identify, analyse and address complex and/or abstract problems drawing systematically on the body of knowledge and methods appropriate to a field;  Identify and address ethical issues based on critical reflection on the suitability of different ethical value systems to specific contexts;  Demonstrate an understanding of the complexities and uncertainties of selecting, applying or transferring appropriate standard procedures, processes or techniques to unfamiliar problems;  Possess the ability to use a range of specialized skills to identify, analyze and address complex and/or abstract problems drawing systematically on the body of knowledge and methods appropriate to a field or discipline ;  Demonstrate the effective use of science and technology;  Critically review information-gathering, evaluation and management processes in specialized contexts in order to develop creative responses to problems and issues;  Present and communicate academic, professional or occupational ideas and texts effectively to a range of audiences, offering creative insights, rigorous interpretations and solutions to problems and issues appropriate to the context;  Operate effectively within a system, or manage the system based on an understanding of the roles and relationships between elements within the system;  Apply in a self-critical manner learning strategies which effectively address their own and others' professional and on-going learning needs;  Take full responsibility for their own work, decision-making and use of resources, and be fully accountable for the decisions and actions of others where appropriate.

Competencies of a nurse educator
A nurse educator should be competent in the following ways: 1.To develop a curriculum that is relevant, evidence-based and competency focused; 2. Develop micro-curriculum material to support the implementation of a macro-curriculum; 3. Create an environment in classroom, clinical laboratory and clinical settings that facilitates student learning and achievement of competence; 4. Use a variety of teaching modalities to promote learning and mastery in nursing students; 5. Creatively integrate reliable and valid formative and summative assessment of students in a teaching/learning programme, in classroom, laboratory and clinical settings, and in all domains of learning; 6. Promote clinical competence by exposing students to appropriately chosen and structured clinical experiential learning; 7. Model clinical competence, professional behaviour and a professional ethos; 8. Supervise clinical preceptors and/or a team of teachers working with the students they are teaching to ensure quality of teaching, staff development, optimal linking of theory with practice and support; 9. Implement appropriate strategies of quality assurance of the clinical and classroom learning experiences of students, including appropriate programme evaluation measures; 10.Keep adequate teaching records of all teaching activities; 11.Function as a change agent and leader to create a preferred future for nursing education and nursing practice; 12. Maintain own competence as a nurse and an educator; 13.Participate in scholarly activities such as doing research and writing scholarly works; 14.Participate in the educational environment to support the work of the institution and the good of the educational process.( Billings and Halstead,2005: 12-14;Halstead, 2007;Mellish, Brink and Paton, 2004.)

Terminology
Assessment: The measurement of the performance of a student or learner against a set of clearly identified criteria.
Comparative education: The comparison of educational systems, processes and outcomes in different disciplines, countries and regions.
Competence: The ability to deliver a specific professional service (Uys & Gwele, 2005).
Course: A building block of a programme, consisting of a time-limited component, usually over one term (3 months), one semester ( 6 months) or 1 year and usually ending with a summative assessment (Uys & Gwele, 2005).Curriculum: Planned learning experiences offered in a single programme (Uys & Gwele, 2005).Design: 'Design' as a noun informally refers to an outline or plan for the structure of an object or a system while 'design' as a verb refers to making this plan.

Development:
Establishing what the best approach, strategy or technique is for using a new device or process to deliver a service or produce a product is referred to as development.
Evaluation: The measurement of performance of an educator, a programme or another component of a teaching process against defined standards.Macro-curriculum: The overall design or blueprint of the programme established by a Curriculum Committee (Uys & Gwele, 2005).

Micro-curriculum:
The course outlines and unit plans, usually developed by the individual teacher (Uys & Gwele, 2005).
Management information: Data about students who enter a programme, their performance in the programme and the output of the programme.Module: A unit within a programme or course which can be examined separately (modular instruction) or at the end of the course (Uys & Gwele, 2005).
Preceptor: A person employed by a HEI to interact closely with an allocated group of students in a specific facility or group of facilities to optimise clinical learning in formal nursing programmes (Nursing Education Stakeholders, 2010).Programme: A coherent set of courses, leading to a certain degree, diploma or certificate.Courses within a programme may be core (compulsory) or optional (electives) (Uys & Gwele, 2005).Simulation laboratory: A laboratory setting in which low or high fidelity simulation is used to mimic the professional practice setting, allowing students to practise without the danger of harming patients.Subject: A clearly identifiable area of knowledge that studies a specific set of phenomena from a particular perspective, often using unique research methods (Uys & Gwele, 2005).Quality improvement: A system of monitoring and evaluation, with defined feedback loops and corrective actions aimed at identifying weaknesses in a performance cycle and improving such performance.

Conclusion
The guidelines are provided to FUNDISA members in order to assist them in improving the quality of the programmes designed to prepare nurse educators.The implementation may take a year or two, since the change of curricula and programmes might need external approval.Nevertheless, it is essential in the current framework of the SANC that universities emphasise the need adequately to prepare nurses who are educators-in-training to become quality nurse educators.