Nursing Education in Pakistan, Trends and Challenges of Future

Nursing profession is the key partner of health care industry which going through transformational changes considering diverse needs arise from the society and population in which it should be practiced. A diverse complex of political, economic, socio-cultural and environmental factor is directly affect profession through numerous routes. Therefore, existing status along with trends and challenges should be consider while planning future direction of nursing education in Pakistan.


Introduction
Health systems across the world is confronting several challenges, and government of nations are struggling to search cost-effective options for enhancement the capacity of their country health sectors [1]. Health care needs of society is going to be changed and variations are expected in the patterns of health related problems at regional and international level because of climate change, burden of non communicable diseases like Cardiovascular problem, cancer and rise in mental health disorders [2]. Nursing exist in mutual beneficial relationship with society as nurses raised need in the society and try to grow on the base of need in the society. Because nurses have obligatory role to the society and interest of nursing profession becomes interest of society [3]. Therefore nursing is considered nucleus of health care cell and become mandatory for the functional survival of this cell [4]. Nursing of present day is totally diverse in comparison to the past and nursing of tomorrow will be absolutely different from today, this future uncertainty of nursing profession is challenging and needs planning to convert threats into opportunities [5]. Although in Asia rate of enrollment in advance education increased in the last two decades to fulfill the society need it also enhanced demand for economy, specialized human resources beside perceived importance of higher education and consequent career opportunities [6]. Nursing education like medical education not easy to impart and face numerous challenges because of its close ties with health of people and therefore emphasis is there for quality enhancement [7]. While to achieve mark of quality and standard it is important to know that influential factors which effect nursing, that is according to " [8]" A complex myriad of political, economic, social, technological, environmental, and legal factors. These challenges become more prominent when it comes to developing countries like Pakistan where a single nurse care about forty patients in average, diploma nursing is in the going pipe to be replaced by degree in coming years but country still send their students abroad for seeking doctorate or post doctorate studies [9]. For effective planning it is important to mention that degree program itself having lot to improve in context to quality enhancement and much work is pending on the part of Nursing regulatory body, institutions and concerned health departments [10]. Due to the key role of nursing in health care sector, In May 2000, the Fifty-fourth World Health Assembly, by resolution WHA54.12 Pass a resolution on Strengthening nursing and midwifery, requested the Director-General to " [11]" prepare rapidly a plan of action for strengthening nursing and midwifery. Which leads to follow-up and development of the first strategic directions for nursing and midwifery in 2002. This paper will critically present a commentary regarding future direction of nursing education in the country keeping in context the existing condition of nursing, future challenges, future Trends to be watch, recommendation for future transformation of nursing education in the country.

Existing Status of Nursing Education in Pakistan
Pakistan is running short of nursing staff, currently nursing education is in transition period and diploma education (hospital bound apprenticeship program) is almost going to be replaced by university degree till the end of this decade. A few universities offer master degree in nursing sciences [9]. However there is lot to be done more as currently degree program is lacking quality with exception to some institution, along with surfacing of some ghost institutions offering degree to remote students even without attendance, reason behind is the culture of political nepotism and corruption [10].

Future Trends
Nursing is going through transformation globally and nursing education gaining socioeconomic attention towards development as profession in health care delivery system [12]. Therefore, following ten trends should be kept in account which has direct impact on nursing education. The identified trends by Heller & Oros are the following:

Diversity in Demographics
Diverse demographics leads to expansion of aging population which consequently demands preparation of nurses to care them.

The Explosion of Technology
Continuous progress in field of technology and the use of tele-health, Nanotechnology and telemedicine made it necessary for nurses to learn new skills in technology and contribute to professional development.

Globalization of World Society and Economy
The world has become a global village and as a result brought drawbacks along with benefits therefore nursing education and research should focus on health care issues that are the outgrowth of globalization.

The Era of the Educated Consumer, Alternative Therapies and Genomics and Palliative Care
Today's patient is more informed than ever because of accessibility to the information regarding their health and to meet the needs of informed patients' nurses require enough knowledge and competencies. Furthermore, nursing education should encourage the use of alternative and complementary therapies as it is the center of focus today to promote health and healing. In addition, graduate nurses should also be prepared to provide palliative and end of the life care in the form of pain management, counseling, support group and spiritual care.

Shift to Population-Based Care and the Increasing Complexity of Patient Care
Increased in costs on treatment of diseases and aging population diverted the concept of health care from cure to prevention and for this purpose nurses should have knowledge and skills of epidemiology, biostatistics and behavioral sciences to be capable of preventing diseases.

The Cost of Health Care and the Challenge of Managed Care
Nursing education and research should be focused on cost effective care, health education, health promotion, and evidence based nursing practice which will prepare students to play their roles in employment and case management.

Impact of Health Policy and Regulation
Nursing leader should play their role and should prepare students for meaningful part in politics.

Need for Collaborative Practice Through Interdisciplinary Education
Nurses should be able to provide quality care for which interdisciplinary education and team based approaches has revealed to be highly effective.
Shortage of nurses and opportunities for lifelong learning and workforce development Nursing educational institutions should have enough resources to produce more and more graduate nurses and should ensure provision of effective and efficient continuing education.

Significant Advances in Nursing Science and Research
Research is an important aspect in improving health and nurses should be engage in the process research to ensure provision of quality care.

Challenges of Future Nursing
Following challenges has been identified by National advisory council on nurses' education and practice (NACNEP) facing by nurses of 21 st century:

Education Practice Alignment
Being active player of health care industry nursing profession must upgrade its status with speed to adjust nurse practitioner ready for safe, quality, effective patient centered care by keeping nurses current, updated and equipped with necessary skills, attitude and knowledge thus to fulfill the desired expected role [13]. Education practice alignment can be balanced with production of Baccalaureate nurses rather than diploma nurses as Higher education and specialized nursing education is positively linked with professionalism [4] In Pakistan new established institution are allowed to offer only a four year university degree for practice and mostly diploma holder nurses education has been upgraded to university level through different courses [9].

Faculty Development Challenges
Quality nursing education required qualified and well prepared faculty. Development of competent faculty and faculty vacancies is important among challenges of future nursing education as Insufficient capacity in nursing institutions leads to competency constrains [13] Few exceptional nursing institutions are equipped with qualified faculty in the country, remaining are something running by nurses who did not match the required criteria teaching faculty either in term of Practice or qualification [10].

Nursing as Part of an Integrated Healthcare Workforce
It is evident empirically that health care practice based inter-professional approach is beneficial in context to care cost and effect but unfortunately barriers like mutual understanding of role and lack of interdisciplinary training are there which snag to practice in such a collaborative way [13].

Recommendation for Future Nursing
Institute Of Medicine gave following recommendations are do followed for future directions of nursing education.
Removal of hurdles which effect full scope of nursing practice, Expansion of diverse opportunities for nurses' cadre, nurses reside ship programs, increases in number of baccalaureate nurses, Prepare and enable nurses to lead change to advance health, and building of necessary infrastructure for advance nursing education and research [14].

Conclusion
Nursing profession is the key partner of health care industry which going through transformational changes considering diverse needs arise from the society and population in which it should be practiced. A diverse complex of political, economic, socio-cultural and environmental factor is directly affect profession through numerous routes. Therefore, existing status along with trends and challenges should be considered while planning future direction of nursing education in Pakistan.