INDEN: "Quality Development in the Nurses Doctoral Education"

Quality Development in the Nurses Doctoral Education from a Swedish Perspective

Ingalill Rahm Hallberg, Professor at the Centre of Caring Sciences, Lund University, Sweden

First of all I wish to thank the organising committee for inviting me to talk about quality in the doctoral education from a Swedish perspective which in fact will be rather from my experience and perspective.

First of all I'll give you a short introduction to Swedish doctoral education in nursing - its development and the stage we are presently at. Then I'll give you an overview of how we try to secure and improve quality. There are slight differences between the universities in Sweden. But in general there are more similarities than differences. Nurses are at present very interested in doctoral education and it is a new and younger generation of nurses who show their interest. This is very important since we in Sweden have a large generation shift in front of us. Within the coming 5-10 years a large amount of those having a doctoral degree will retire. There may be a gap that needs to be filled out and filled out by nurses that are able to look critically at what we have done.

The more formalised doctoral education in nursing goes back about 20 years. Before that and the first years thereafter the doctoral education took place mostly in the faculties of human or social sciences and that means in fact that those nurses did not get their doctoral education in nursing but in subjects such as psychology, sociology or pedagogic. That of course had it pros and cons. The most important shortcomings were that they had their education away from those who were the most important future collaborators, that is to say the physicians. Also they were supervised by people who had no knowledge of nursing as an academic subject or as a profession.

Today the doctoral education in nursing takes place within the medical faculties at the universities having the medical sciences as a scientific domain. This is a recent development and means that one can have a doctoral degree in nursing (equivalent to a PhD) to at one of the six large universities in Sweden. At those places the education of physicians, nurses, physiotherapists, occupational therapists and some other health care workers take place together in the same faculty - from their basic education to their doctoral education. In this very latest development I can foresee great benefits but also note that we have to make sure that we preserve and develop the unique character of nursing research. This means that we should not be afraid of but rather develop our research collaboration with physicians. Right now, at our faculty, we have different groups each with the task to outline a programme for the development of research, doctoral education and basic education for the following ten years. I am certain that the outcome of these workgroups will be that of integration but also of diversification. Because the needs and thereby the curriculum for the doctoral education is very different for nurses interested in human beings compared to highly biomedical researchers.

Currently the doctoral education in nursing has two parts; the theoretical part which is made up of courses; some of which are mandatory and others that are elective and decided upon by the principal supervisor together with the doctoral student. The second part is the dissertation, which is the main part of the doctoral education. There are two ways to do a dissertation in Sweden. Either you do what we call a monography or you do a composite dissertation. The first type means that the dissertation is written up as a book with chapters and prepared at the end of your study period. The other type means that the dissertation consists of internationally published papers. These papers should be published in scientific journals with a referee system for reviewing the papers and be represented in databases like Med-line. This second type is the most common type of dissertation from medical faculties and also for nurses. The doctoral education is a four-year full-time study programme and the theoretical part is in most cases no more than one year and the thesis a three-year study.

Looking at this from a quality perspective I would like to address four critical points of the education - how we try to meet these critical points and, from my perspective, what are the problems at present. The four critical points are:

Taking on students into the doctoral programme;

The process and support throughout the programme during which some of the students probably should stop at a lower level and others should continue to a doctoral degree;

The ensuring that the dissertation has an acceptable standard and the student the qualification that is required for a doctor in nursing;

The last critical part, as I see it, is that of supporting and preparing principal and co-supervisors into the role of supervising doctoral students in nursing. This last point, I would say, is at present the most critical point for the development of quality in Swedish doctoral education of nurses.

I'll start off by commenting on the first point, that of taking doctoral students into the programme. Apart from meeting the formal demands, which I am not going to comment on, there are two aspects that need to be taken into consideration when taking on a doctoral student. These are the students' intellectual capacity and the students' capacity to express themselves in writing. From my experience some students are very skilled in passing courses but not so skilled in analysing or developing new thoughts, theories or expressing themselves or their ideas in writing by them. So the task of selecting the right people into the programme is a critical one. Also the doctoral student may be weak in preparation for doing research and that may hide their intellectual capacity.

The way we go about this is that the doctoral student is not eligible until he or she has made a full proposal for the entire dissertation in collaboration with the presumed principal supervisor and in same cases also with the co-supervisors. Preparing this research plan can provide the supervisor with a rather good impression of whether the student has the qualifications needed to go on with the studies. Risks can be identified one of, which is the pressure on the supervisor to take on doctoral students. From a quality perspective it would have been nice to have a test-period during which the student was expected to write up a piece of empirical research for publication. This is done, but it is doubtful whether this is correct according to the regulations.

Serving the interest of high quality, I believe, is the fact that the core component in the doctoral education is the close relationship between the supervisor and the student meaning that the student, in most cases, receives strong individual support. A close mentor - mentee relationship. As you all know this is also demanding in that the close relationship can go wrong. As we all know all marriages do not last forever - and this goes also for the relationship between a supervisor and a supervised. In my opinion this relationship requires insights into handling a close relationship from a psychosocial perspective. Another benefit with this system is that the student starts with the research part of the doctoral studies from day one. This makes it easier when it comes to selecting those who are able to carry out empirical research from those who are best on doing courses only. A critical part is that they may not be theoretically well enough prepared for planning and setting up research. Thus we, at my faculty, talk more and more about initial research education providing the student with the necessary theoretical knowledge about research design and methods.

The second area of importance for securing quality, is the process or the ongoing work with the dissertation and the theoretical studies. Here we have some ingredients which I believe are of great value. At most departments, I believe, and certainly at our department we have regular seminars in which the doctoral students are taking part which is mandatory. The seminars focus, mostly, on the drafts for a presumed publication or the research plan if it is a new doctoral student or a new study. These seminars take place every third week. In my opinion this is the other core component in the doctoral education and important for securing quality. The seminar group must not be too small to reach a sufficient critical mass for creative intellectual debate and sharing of ideas and knowledge (12-16 people). Because of these seminars the students are trained to think critically, take and give criticism and hopefully this strengthens their critical thinking. Since our doctoral programme is highly individual, we can organise courses or seminars or workshops that meets the students needs at a specific point in time.

Another strength with the composite dissertation is the fact that the student gets continuous feedback from the international research society. This has at least two important consequences with regard to quality - firstly the student and also the supervisor gets feedback from the international society and secondly the student learn to take criticism and hopefully improve their research skills but also to take criticism without taking it personally.

Also, recently, it was decided that all doctoral students should have what we call a mid-seminar. To these seminars two highly qualified researchers should be invited. These researchers are supposed to work through the future dissertation with the doctoral student. This is a seminar open for the doctoral students and the doctors in the department. Before the seminar, the student in focus is supposed, to have two papers published, one or two in progress and a draft for the framework of the future dissertation. This is a very good opportunity for her or him to review critically what has been done, to plan forward and to improve the weak spots of the dissertation and thus improve quality. The more skilled and experienced researchers one can invite to be the opponents at this point in time the more opportunities are provided to the student and the supervisors to improve the dissertation.

There is of course a risk that the supervisor selects a "too sympathetic researchers" for the mid-seminar. The very great problem at this point of the doctoral education, however, is to support some of the students to stop at this stage of the education and be happy with what we call a licentiate examination. This is half a doctoral degree. This is a requiring task since the student and also the supervisor may, for other reasons, want the student to go for a doctoral degree. The other weak point is the fact that taking Sweden as an example we do have six professors in nursing and about 20-25 associate professors, which is the lowest requirement for becoming the principal supervisor. Becoming an associate professor in Sweden is an academic level after dissertation and earning it requires, after the doctoral dissertation, to have done at least twice as much research as the dissertation (normally 15-20 internationally published original research). The professors and associate professors supervise all together hundreds of doctoral students in nursing.

The third domain for quality control and improvement is the last stop before defending the dissertation. In Sweden defending a dissertation is a public event and anyone can stand up as an extra opponent at this point. The procedure is that four months before the planned defence of the dissertation the principal supervisor has to report the student to a research committee. Before this report three senior researchers shall review all publications that are supposed to be part of the dissertation. They should give a written statement as to whether these papers meet the quality requirements. Thereafter permission is given to the doctoral student to go on with the dissertation or to improve their work. If the student gets permission the framework of the dissertation is to be sent to the research committee no later than three months before the defence date and thereafter the final decision is to be made whether the student is to be allowed to defend the dissertation. An examination committee is selected as well as an opponent and a chairman for the defence. The examination committee is made up of three skilled researchers, one taken from another university, another from another faculty of the university and the third, a senior researcher from the department of the student. At our university the lowest requirement for belonging to an examination committee is an associate professorship. The members of the examination committee are supposed to "blow the whistle" if they see any problem with the dissertation before the public defence. This is to give the student the opportunity to withdraw the dissertation if there are doubts about the quality.

Lastly, what I believe to be the most important area for quality improvement of the doctoral studies at present. That is the preparation and support of the principal supervisors and a system for preparing co-supervisors to become skilled principal supervisors. At present we do not have any established supportive system for supervisors. At most of the universities the requirements for becoming the principal supervisor is to be an associate professor, which in fact does not include any preparation for supervising doctoral students, only research experience. In reality, the situation in Sweden is that most of our doctors in nursing are involved in supervising doctoral students from the first day after their own dissertation and in many cases without any network supporting them in this process and demanding task. I believe this is a threat to quality in doctoral education and also a threat to the research because these newly graduated doctors do not set up their own research and are not giving the opportunity to develop their own research skills. They have to adapt themselves to the level of the doctoral student instead of the opposite.

Beside this we do not have a supportive system for those involved in doctoral education providing them neither with the formal knowledge needed for instance about their legal responsibility, theoretical and methodological development nor with room for reflection about the very sensitive psycho-social process of supervising. It means living so close to another person for a long period of time and during which the student is supposed to reach out for new knowledge that makes a difference for practise.

This is the reason why I have started up a support group for supervisors in the southern region of Sweden. This group is planned to meet on a regular basis with the objective to increase our skills as supervisors. The way I see this new development is that it will be a mixture of informing ourselves about legal and pedagogical aspects as well as sharing each others experience with regard to the process and with regards to planning a doctoral dissertation. It feels like what we are doing is like a "drop of water in the ocean" - however we have to start at some point. For me this is an important step to take - to provide supervisors with a supportive environment and a system to develop quality in nurse doctoral education. In the meantime I'll fight for a more systematic supportive system within the faculty.