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DISCUSSION PAPER

JOURNAL OF ADVANCED NURSING

Nursing education in Denmark, Finland, Norway and Sweden from Bachelors Degree to PhD
Maj-Britt Raholm, Birte Larsen Hedegaard, Anna Lofmark & Ashild Sletteb
Accepted for publication 5 March 2010

Correspondence to M-B. Raholm: e-mail: majbritt.raholm@hsh.no Maj-Britt Raholm PhD RN Associate Professor Faculty of Health, Stord/Haugesund University College, Norway Birte Larsen Hedegaard PhD RN Associate Professor Faculty of Health, VIA University College, Viborg School of Nursing/The Regional Hospital, Denmark Anna Lofmark PhD RN Associate Professor Faculty of Health, Stord/Haugesund University College, Norway, and Department of Caring Sciences and Sociology, University of Gavle, Sweden Ashild Sletteb PhD RN Professor Faculty of Health and Sport, University of Agder, Arendal, and Faculty of Nursing, Oslo University College, Norway

RAHOLM M-B., HEDEGAARD B.L., LOFMARK A. & SLETTEB A. (2010)

Nursing education in Denmark, Finland, Norway and Sweden from Bachelors Degree to PhD. Journal of Advanced Nursing 66(9), 21262137. doi: 10.1111/j.1365-2648.2010.05331.x

Abstract
Aim. This paper is a discussion of the similarities and differences in baccalaureate nursing education programme structures, content and pathways to postbaccalaureate education in the Scandinavian countries. Background. For the last three decades nursing education internationally, as well as in the Scandinavian countries, has experienced ongoing reforms. The driving forces behind these reforms have been efforts for professional development within nursing and to harmonize higher education in several European countries. Data sources. The data were collected by a critical review of the guiding principles, national directives and educational structures and content of Bachelors degree programmes from 1990 to 2008 and of further educational levels in the four Scandinavian countries. Discussion. There are similarities as well as substantial differences in the educational structures, contents and lengths in the different nursing programmes. Nursing education is organized in the three cycles described in the Bologna Process, but there are differences regarding names and terms for degrees and allocation of European Credit Transfer System credits. Implications for nursing. Policymakers need to consider more carefully the directives in the Bologna Declaration when planning and implementing nursing programmes at Bachelors and postgraduate levels. Knowledge of the content and structure of nursing education in these countries may enhance development and cooperation between institutions. Conclusion. A challenge for the ministries of education in the Scandinavian countries is to compare and coordinate nursing educational programmes in order to enable nursing students, educators, researchers and nurses to study and work in Scandinavia, Europe or even globally. Keywords: Bologna Process, competencies and Scandinavia, curricula, harmonization, nursing education, professional development

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Introduction
For the last three decades nursing education internationally as well as in the Scandinavian countries of Denmark, Finland, Norway and Sweden, has experienced recurring reforms. The driving forces behind these reforms have been efforts for professional development within nursing (Gerrish et al. 2003), and efforts to integrate the nursing programmes into higher education. The Bologna Process is the latest of these reforms, and its aim is to create convergence among a number of European countries to harmonize higher education in (Davies 2008). From an international point of view, the nursing profession varies by country in how it is regulated. Regulation has taken a variety of forms, and in some countries nursing has not yet become an autonomous, regulated profession. Differences in regulatory criteria are barriers to internationalization (ICN/WHO 2005). Although the ideal of worldwide standards for nurses promoted by the ICN for over a century remains unrealized, the forces of globalization have created impetus for change. Among the projects focusing on quality in nursing education is the recently formed Joint Force on Creating a Global Nursing Education Community (WHO/Sigma Theta Tau Honor Society of Nursing 2007). While international and national nursing bodies are focusing on international standards for nurses, there are also movements such as the Bologna Process, which concentrates on educational harmonization involving national governments. The European Ministers of Education (1999) promoted six objectives: (a) to adopt a system of academic degrees which are transparent and easily compared, including the introduction of the diploma supplement, (b) to adopt a system based on two cycles: the undergraduate cycle of 3 years of study, which is mainly aimed at providing qualied personnel for the job market; and the postgraduate cycle for Masters and doctoral degrees, conditional upon completion of the undergraduate cycle; (c) to establish the European Credit Transfer System (ECTS); (d) to promote

the mobility of students, teachers, and researchers; (e) to promote cooperation in quality assurance; and (f) to promote European dimensions in higher education. The ECTS makes teaching and learning more transparent and facilitates the recognition of studies. The system is used throughout Europe for credit transfer (student mobility) and credit accumulation (learning paths towards a degree). It is also an aid in curriculum design and quality assurance (European Commission 2009). Scandinavian countries have similar cultural, religious, social and political environments, including similar healthcare structures. Furthermore Danish, Norwegian and Swedish belong to the same language group, and communication is possible without shifting to a second language. The Nordic Council of Ministers, which represents the countries where these languages are spoken, as well as Iceland, has encouraged major collaboration on educational programmes, research and teacher and student exchange (Nordic Council of Ministers 2009). The number of inhabitants in each of the Scandinavian countries is small, but altogether approximately 25 million people live in the four countries, and around 300,000 Registered Nurses work there (Table 1).The geographical, cultural and linguistic proximity enable nurses to work in all Scandinavian countries. Table 1 shows the number of inhabitants and recently Registered Nurses in each of the four countries and the number of nurses employed in each country in total in 2006. It also shows that Norway employs the highest number of nurses from other Nordic countries.

Background
Professionalization and professional development are oftenused terms in nursing, but they are not always clearly dened (Ryan 2003). Throughout history, professionalization has played an important role in the development of the nursing profession in Scandinavia. Professions have been dened as occupations which are knowledge-based and

Table 1 Population and registered nurses in the Scandinavian countries in 2006

Population (total), million 54 52 46 91 243 Registered (own country) 1860 2453 3552 4577 12,442 Registered (Nordic countries) 84 17 1687 112 1900 Registered (other countries) 56 54 289 89 488 Registered (total) 2000 2524 5528 4778 14,830 Registered nurses in total and working as nurses 55,556 70,889 60,929 112,021 299,395

Country Denmark Finland Norway Sweden Total

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achieved after following years of higher education and/or vocational training (Evetts 1999, p. 120). Hilton and Slotnick (2005, p. 62) dene six domains of professionalism: ethical practice, reection and self-awareness, responsibility for actions, respect for patients, teamwork and social responsibility. Evetts (1999) proposes a traditional view on professionalization, and argues that professionalization is a diverse process in which professional development takes its own course in different countries. Historically, professionalization in nursing education has followed a similar path in Scandinavia. It can be divided into two epochs the training epoch and the academic epoch. Struggles towards professional development have characterized both eras.

19th century, the scientic foundation for the medical profession changed dramatically from a metaphysical towards a clinical experimental foundation. Nurses insisted on the original foundation and therefore on metaphysical, humanistic and social scientic changes. Nurses struggle for professional recognition and an academic anchoring of nursing practice, education and research has continued until today (Larsen 2006).

The academic epoch

Reforms in Denmark, Finland, Norway and Sweden in the late 20th century have changed nursing education from an apprenticeship system to a higher education system. This became reality in Denmark in 1990 (Executive Order 1990/ 143), in Finland in 1990 (Salminen 2001), in Norway in 1983 (Kyrkjeb et al. 2002), and in Sweden in 1977 (Kapborg 1998). Subsequently, undergraduate nursing education was integrated into university colleges, universities of applied sciences and universities. According to Karseth (2004), this shift implied greater economic, administrative and professional independency for the nursing profession. The guiding principles of higher education require that nursing education should be based on scientic and practical knowledge, and thus should provide students with the necessary knowledge for working in the profession and being well-prepared for tomorrows labour market. In the Scandinavian countries, nursing studies at doctoral level were fully integrated into the higher education system after 1979. Nursing research had previously been linked to other scientic disciplines. Opportunities for doctoral studies gave the nursing profession the chance to develop as an academic discipline and enhance professional autonomy. Care science scholars such as Kari Martinsen and Katie Eriksson have inuenced the professionalization of nursing and the debate among nurses extensively from the 1970s until today (Eriksson 1985, 1987, 2001, Martinsen 1989, Martinsen & Eriksson 2009). On the basis of the Bologna Process, nursing education is now regulated by Higher Education Acts in each country. In Norway (Act-2008-1212-105) and Sweden (SFS 1992:1434) the Act is the same for universities and university colleges, while in Denmark and Finland there is one Act for universities (2003/403 and 1997/ 645) and one for universities of applied sciences (2000/481 and 2003/351). The Act of Finnish Universities is under reform and will gain legal validity in 2010. In this paper, we present a discussion of the similarities and differences in baccalaureate nursing education programme structures and content and in pathways to postbaccalaureate education in the Scandinavian countries.

The training epoch

Florence Nightingale (18201910) exerted the most dominant inuence over Scandinavian nursing history. Her educational and hospital plans were implemented in all Scandinavian countries. When Nightingale organized nursing education in London from 1861 onwards, students came from all over the world to attend her school, and after completing their studies they returned to their home countries, mostly as managers and educators. Nursing education was, in its early phase, dominated by students working in the clinic to obtain their training, which was organized in accordance with an apprenticeship system (McMillan & Dwyer 1989, Tallberg 1994, Sarkio 2007). In the early 1900s, when nursing education changed gradually from hospital-based training to educational programmes containing shorter theoretical periods of study, conicts arose between the nursing and medical professions regarding professional recognition. Nightingale emphasized that nursing was an autonomous profession with the following essential elements: rst, knowledge of the characteristics of sickness, health and health promotion initiatives and, second, knowledge of the characteristics, duties and skills of the female sex. To her, the rst and the latter were founded in metaphysical theories concerning human health equilibrium, sickness and health and human biological characteristics, respectively. To Nightingale, there were no differences between the scientic level of theories related to medicine and those related to sexual characteristics. Therefore there were no relevant scientic distinctions which could justify nursing as a subordinate profession to medicine (Nightingale 1859, 1860, Cook 1913, Larsen 2006). From the very beginning of the history of modern nursing, nurses strongly defended this view. Metaphysical theories of sexual characteristics changed over time. In the last part of the
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Scandinavian nurse education systems

Content and structure of nursing education in the Scandinavian countries
The general plans for nursing education in Scandinavia (Executive Order 2008/29, Academic regulations 2008, http://www.minedu. 2006, The Polytechnic Act 9.5 2003/ 351, http://www.safh.no, White paper no 27, 2001, SFS 1993) show many similarities. They are, for example, nationally-based and set a standard for nursing education. They include aims and contents for the curricula. Some offer detailed content, while others are more general. Universities, university colleges and universities of applied sciences with nursing programmes compile their own curricula based on the national general plans. The curricula include information about organization, progression, clinical education and the relationship between theory and practice. Approval of the quality of the programmes is set by a national agency for higher education in each country. According to the Bologna Process, the general plans require that nursing students develop different kinds of competencies: a) theoretical-analytical competence implies the ability and will to learn through observation, analysis, reection and systematization, b) practical competence, which is the ability

to implement knowledge in the form of systematization and problem-solving skills, c) learning competence, which refers to the ability and will to acquire new knowledge and apply this knowledge in new situations, d) social competence, which refers to students ability to establish and sustain interpersonal relationships, e) professional ethical competence, which enables students to be capable of ethical justications in relation to regulations and ethical guidelines (Bologna Declaration 1999). The academic and professional foundation of the nursing programmes is based on theoretical and clinical knowledge from the eld of nursing in interplay with subjects such as healthcare science, natural science, social sciences and the liberal arts (Table 2). A nurse with a Bachelor of Science Degree in Nursing is qualied to work as a Registered Nurse, to enter into interdisciplinary cooperation and to enrol in university second cycle programmes in nursing and healthcare sciences. The fact that nursing research has increased contributes to the expansion of a specic body of nursing knowledge. National and international research results are included in the programmes, which are organized to allow professional, academic and innovative competences develop in dynamic interaction between theory and practice. The general plans emphasize that nurses should relate to the patients as whole persons, taking into consideration the

Table 2 Scientic areas and core subjects

in Bachelor of Science in Nursing in Scandinavia Country Denmark

Scientic areas and core subjects Nursing science Medical science Natural science Humanities Social science Nursing science Theoretical and scientic basis of nursing Professional/clinical studies ICT, R & D Communication and Languages Social science Natural and medical science Optional studies Nursing science Theoretical and scientic basis of nursing Nursing theory and practice Medicine and natural science Social science Nursing science Medical science

ECTS credits 120 40 25 15 10 6 75 6 9 6 15 3 33 72 45 30 1265 535

All together 210 120 theoretical 90 clinical

Thesis 20

Finland

210 120 theoretical 90 clinical

15

Norway

180 90 theoretical 90 clinical

12

Sweden

180 135 theoretical 45 clinical

15

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physical, mental, social, cultural and spiritual aspects. Furthermore, nurses should reect on how healthcare problems relate to political and economic conditions. They should also cooperate with other healthcare professionals and social workers. Facilitating nursepatient communication, coordinating patient-related teamwork and supporting patients to take an active part in the recovery process are essential components of nursing education (Executive Order 2008/29, Academic regulations 2008, http://www.minedu. 2006, Act 2003/351, http://www.safh.no, White paper no 27, 2001, SFS 1993). When analyzing the nurse education curricula in the Scandinavian countries, differences can also be seen. In Denmark, nursing education at the Bachelors level encompasses studies in four scientic areas (Table 2) nursing science, medical science, natural science, humanities and social science. The nursing programme consists of 120 theoretical and 90 clinical ECTS (European Credit Transfer System) credits. The Bachelors dissertation is allocated 20 ECTS credits. Altogether, 14 core themes are covered through research, developmental and practically-generated knowledge and incorporated into clinical learning activities. The term knowledge inuenced by the knowledge forms of Aristotle, is understood in nursing broadly as scientic, technical and ethical knowledge. Students are expected to work as reective practitioners. They are expected to provide total care for patients and develop methods for assessing, reecting, planning, conducting, evaluating and developing nursing and assisting medical treatment (Academic Regulations 2008). In Finland, the Act of Higher Education (351/2003, 426/ 2005) stipulates that studies leading to a degree from a University of Applied Sciences provide the necessary skills for tasks requiring professional expertise (Table 2). In accordance with the Governments Act on Universities of Applied Sciences (352/2003), studies are grouped as basic and professional studies, optional studies, clinical studies (90 ECTS credits) which enhance professional skills, and a Bachelors dissertation (15 ECTS credits). Nurses professional competence is based on knowledge of nursing science as well as theoretical and practical skills (Ministry of Education 2006). Additionally in Finland, nursing students must also study three different languages: Finnish, Swedish and English. In Norway, the general plan for nursing education describes the aims, scope and content of the curriculum as well as evaluation requirements and required skills on completing the programme (Ministry of Education, Research and Church Affairs 2000, 2005). The content requirements in the general plan for nursing education in Norway are that 50% of the curriculum should be clinical studies (Table 2).
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The Bachelors dissertation should be at least 12 ECTS credits. The focus of their education enables nurses to provide total care for patients and to develop clinical methods for nursing patients with different conditions and assisting medical treatment. Nurses are educated for knowledgebased work, which means using evidence-based nursing, experience-based nursing and focusing on client-participation (http://www.safh.no). According to the objectives in the national guidelines in Sweden (SFS 1992:1434, SFS 1993:100) and the Bologna directives, the expected outcomes are described in specied domains of knowledge and understanding, skills and abilities, judgement and approach for certication as a nurse. Universities and university colleges in Sweden are relatively free to develop their own and local curricula for nursing programmes; however, they are continuously scrutinized by the National Agency for Higher Education. Table 2 shows two main scientic areas, nursing science and medical science. Other university colleges and universities have a more detailed description where social and behavioural subjects are specied. The Bachelors dissertation is stipulated as having 15 ECTS credits. Programmes are arranged in courses, some covering both theory and practice. The EEC Agreement (DS 1992:34) states that the nursing programme should comprise both theoretical and clinical studies.

Harmonizing nursing education in Scandinavia according to the Bologna Process

According to Davies (2008), the Bologna Process is a quiet revolution in higher education, affecting nursing education in many countries in Western Europe. The Bologna Declaration indicated that degree programmes should be organized at both undergraduate and graduate levels (European Ministers of Education 1999, Zeabalegui et al. 2006, Spitzer & Perrenoud 2006a,b). In addition to The Bologna Declaration, nursing programmes have been subjected to two European directives regarding the qualications of nurses responsible for general care. These are directives 77/453/ECC of June 27, 1977 and 89/595/EEC of October 10, 1989, which require that a degree programme should be at least 3 years or 4600 hours. These directives do not indicate academic status requirements for registration (Zebalegui et al. 2006). According to Davies (2008), The Bologna Process offers real opportunities for nurses to establish closer links with their European colleagues across spectra of clinical practice, management and academia and to raise the prole of nursing as a graduate profession. In 2000, a group of university leaders met the Bologna Process challenge collectively and designed a pilot project

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titled: Tuning educational structures in Europe (Gonzales & Wagenaar 2005a). The Tuning Project should enhance curriculum development, e.g. in nursing education. During the Tuning Project, a methodology was designed to make different nursing curricula comparable across countries. The following descriptors have been designed in recognition of the Dublin descriptors (http://www.jointquality.org). According to Gonzales and Wagenaar (2005b), the Tuning Project has specied descriptors for rst, second and third cycle degrees. First cycle descriptors include, for example, that a nursing student should be able to analyse professionoriented issues theoretically and apply this awareness in practice, and be able to document, analyse and evaluate various types of nursing practices. The second cycle descriptors include development of academic knowledge on an independent basis in order to be able to apply scientic theories and methods. Third cycle descriptors include the student achieving competences based on empirical work that includes original research conducted on an independent basis (Nursing and Midwifery Council 2009). In the Scandinavian countries, pathways based on the threecycle system medio 2008 can be illustrated as in Table 3.

Academic pathways from Bachelor of Nursing to PhD

In Denmark (Table 3), the objectives for nursing education are to qualify nurses to act autonomously and to participate in interdisciplinary cooperation regarding patient care. The objective is also to qualify nurses for further academic and scientic education. Danish nurses are qualied at the Bachelor level, and are registered in accordance with national regulations and national supervision and control (Act 2006, Executive Order 2008/29). Danish nursing education follows the three-cycle model. The rst cycle takes place in university colleges, and the second and third cycles in universities. It is a prerequisite for entering nursing education that students have completed secondary school or have corresponding competencies. When entering nursing school, students attend a 35year (210 ECTS credits) professional Bachelors degree programme and obtain the degree Bachelor of Science in Nursing (Table 3). A professional Bachelors degree in nursing is the pathway to being a Registered Nurse and to further education in nursing and healthcare educational programmes. The title candidate is used for the highest scientic degree in the second cycle (120 ECTS credits) and is the pathway to the third cycle, PhD level (180 ECTS credits). The term Master is used for a professional degree in the second cycle (6090 ECTS credits). A prerequisite for enrolling in Masters programmes is 25 years work experience. In order for a Masters degree holder to continue

studies at doctoral level, a supplementary scientic programme at a University is required. For nurses educated in previous non-academic programmes, a diploma qualication (60 ECTS credits) can be achieved, equivalent to a Bachelors degree in the rst cycle (Ministry of Education 2003, 2008). Specialist nursing programmes are not part of the Bologna educational system. In Finland (Table 3), a Bachelor a programme in nursing consists of 210 ECTS credits. This is a 35-year full-time programme of 60 ECTS credits/year (Table 3). In Finland, there are opportunities to pursue specialist nurse studies (2030 ECTS credits) in, for example, psychiatric nursing, operating theatre nursing, nursing older people, etc. This specialization is not part of the Bologna system. In 2004, the question was raised about juxtaposing second-cycle Masters degrees from universities of applied sciences (professional master) with Masters degrees obtained at universities. The relevant degree amendment was actually made in 2005 (A423/2005). At universities of applied sciences, students cannot automatically proceed to second cycle studies, but rst have to acquire a minimum of 3 years of work experience. The objective concerning student intake is that 20% of rst cycle graduates will take their secondcycle professional degree. A Masters programme at the university level requires 120 ECTS credits, which means 2 years of full-time studies. Postgraduate studies (licentiate degree and doctorate) take a further 35 years (Paulin 2003). Students admitted to university education in nursing science are those who already have a Bachelors degree in nursing and those who have just completed their matriculation examination at upper secondary schools (i.e. people who have no earlier education in nursing). A candidate degree at the university still has the status of an intermediate degree in Finland. Students may complete it if they wish, but it is not compulsory (Ahola & Mesikammen 2003). In Norway, the Bachelor of Nursing programme (Table 3) consists of 180 ECTS credits. This means a 3-year full-time programme of 60 ECTS credits a year (Kyrkjeb et al. 2002). In 2005, the rst Bachelor of Nursing Science degree was offered at university level. Obtaining a bachelors degree in nursing from a university college is still the regular route in Norway. At the universities, as well as at certain university colleges, students can pursue a Masters and doctoral degree in nursing science. In Norway, there are opportunities to pursue specialist studies in nursing (6090 ECTS credits) in, for example, intensive care and operating theatre nursing. This specialization is not part of the Bologna system, however. These specializations are possible at present during rst-cycle studies, but there are changes to come where these courses will be part of Masters degree/second-cycle studies.
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2132 Finland University PhD, 240 credits (may include licentiate degree) Related Health science candidate programmes, 2 years 120 credits Masters Degree, 120 credits Suppl scientic programme, 1 year 306090 credits Masters Degree, 6090 credits (Three years of working experience acquired) PhD, 180 credits University College of Applied Sciences Norway Sweden PhD, 120 credits Masters Degree, 90120 credits Masters Degree, 120 credits Suppl courses, 60 credits Magister, 60 credits, Theoretical or specialist nursing education Candidate programme, 180 credits Bachelor of Nursing, 3 years 210 credits Bachelor of Nursing, 3 years 180 credits Bachelor of Nursing, 3 years 180 credits Bachelor of Nursing, 3 years 180 credits Bachelor of Nursing, 3 years 210 credits Master in Clinical Nursing and related health science master programmes, 11 years 6090 credits Bachelor of Nursing, 3 years 210 credits

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Table 3 Academic pathways from Bachelor of Science in Nursing to PhD

Cycles

Denmark

PhD, 3rd cycle

PhD, 180 credits

Master, 2nd cycle

Cand cur, 2 years 120 credits

Bachelor, 1st cycle

Bachelor of Nursing, 3 years 210 credits

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60 ECTS credits acquires full-time study/year. Specialist courses outside the Bologna Process are not included in this table.

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In addition, there are opportunities to obtain a Masters degree of 90120 ECTS credits and study at PhD level with an additional 180 ECTS credits. The Swedish nursing programme extends over 3 years and results in a degree named Bachelor of Science in Nursing and the professional qualication to work as a nurse. It is a 3-year full-time programme consisting of 180 ECTS credits (SFS 1992:1934). The nursing programme (Table 3) is taught at both universities and university colleges. Nursing students can pursue a Masters degree for 1 year, receiving 60 ECTS credits for a degree called Magister, or 2 years of study receiving 120 ECTS credits and giving a Masters degree At universities and at most university colleges. Another 2 years of full-time study is the pathway to a doctoral degree in nursing science, encompassing altogether 420 ECTS credits. When the Bologna Declaration was implemented in Sweden 2007, specialist nurse education became part of the second cycle (60 ECTS credits), leading to a specialist graduate diploma, e.g. in midwifery or primary health care.

Discussion
The data raise the question of to what extent the content, structures and pathways to further education in nursing are harmonized in the Scandinavian countries. To our knowledge, this question has not been explored before.

Nursing science as the main subject in nursing education

At rst glance, the content of nursing education at the Bachelors level seems to differ substantially in Scandinavia (Table 2). However, closer examination reveals that in all Scandinavian countries, in spite of differences in the allocation of ECTS credits, nursing science is the main subject. It also reveals that other scientic areas, such as the medical, natural and social sciences, are important complementary subjects. From the 1960s, nursing science in Scandinavia was inuenced by care science scholars in the United States of America, such as Virginia Henderson and Dorothea Orem. In the 1970s, an oppositional trend appeared in the Scandinavian countries. This trend was mainly due to the Finnish care science theorist and nurse Katie Eriksson and the Norwegian philosopher and nurse Kari Martinsen (Alvsvag 2006, Lindstrom et al. 2006). The perspectives of Eriksson and Martinsen have inuenced nursing education curricula in all Scandinavian countries until the late 1990s. Katie Eriksson has, extensively from the 1970s until the present, inuenced the professionalization of the nursing programmes in terms of education, research and practice,

especially in Finland and Sweden. According to Eriksson (1985), one of the problems for the academic anchoring of nursing was that the scientic eld of nursing had not yet been created. She also claimed that the new curricula should be based on a caring science-centered model in which the leading principle was that every educational programme for healthcare professionals was to be grounded in its own scientic basis. Another principle emphasized by Eriksson was that the starting point of academic education and research is knowledge about the eld and object of research, not primarily practical activity (Eriksson1987). The central idea of caring and the substance of nursing were made visible through the caring process model developed by Eriksson, which since the 1970s has been well-known in Scandinavian nursing education (Eriksson 1987). Finnish professors such as Hentinen (1988, 1998) and Lauri (1998) have also contributed to the professionalization of nursing and nursing education by systematic construction of theory within the discipline. In Denmark and Norway, Kari Martinsen has extensively inuenced the professionalization debate among nurses. She described nursing as a primarily ethical discipline. Martinsen referred to Aristotles three forms of knowledge episteme, techne and phronesis and argued that phronesis is the superior among these (Martinsen 1993). Discussing scientic knowledge in nursing, Martinsen (1989) argued that nursing research had to be generated closely to the clinical eld and to be qualitative, with a focus on phenomena essential to patients and nurses. Knowledge in nursing had to be care-oriented (Martinsen 1989). Martinsen discussed the professionalization of nursing from two perspectives nursing as a person-oriented profession and as a scientic-oriented profession and claimed that nurses must dene the orientation of their tasks. To her, the person-oriented perspective should be superior to the scientic, and ethics should be superior to science. However, scientic knowledge was indispensable in assessing a patients health situation and need for nursing. When deciding how to act, nurses need to assess the diagnoses, prognoses, treatment and nursing possibilities related to the illness-oriented factual conditions Assessments of what is best for the patient are crucial and have to be considered from both ethical and technical viewpoints before making any decisions (Martinsen 1993).

Harmonization of higher education

In a cultural, political and economical entity like Scandinavia one might expect a high level of harmonization in nursing education. In this paper, we have shown that there are
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What is already known about this topic

For decades, initiatives in Scandinavian countries have encouraged student/teacher and nurse exchange and research collaboration. Nurses struggle for professional recognition and an academic anchoring of nursing practice, education and research has continued throughout the past century. A harmonization process in European countries known as the Bologna Process has focused on educational structures and content at the bachelors degree level and on pathways to further education.

What this paper adds

In spite of the Bologna Process, there are different amounts of ECTS credits, content and names of degrees in nursing programmes in the Scandinavian countries at all stages. Although the Scandinavian countries have cultural, geographical and linguistic similarities, differences in these areas may prove to be obstacles for further cooperation and, for example, exchange programmes. A common platform for the professionalization process has played an important role in understanding and communication between nurses and nurse educators in the Scandinavian countries.

Implications for practice and/or policy

Policy-makers in nursing education need to consider the directives of the Bologna Process more carefully when planning and implementing bachelors degree education and pathways to further education in the Scandinavian countries. As each of the Scandinavian countries is small, deeper awareness of the content and structure of nursing education and postgraduate studies in the eld may contribute to a valuable exchange of ideas. It is essential to examine common features of the nursing programmes in order to achieve international standards. similarities but also substantial differences in the programmes in the Scandinavian countries, despite the Bologna Process and Tuning Project. The most notable similarity in all Scandinavian countries is that nursing education is organized in three cycles in accordance with the Bologna Process. Yet there are differences in the names and terms of degrees and allocation of ECTS credits.
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Bachelor of Nursing programmes in both Denmark and Finland are placed in the rst cycle and consist of 210 ECTS (35 years of full-time studies). In Norway and Sweden, these programmes are placed in the rst cycle but consist of 180 ECTS (3 years of full-time studies). In Denmark, Finland and Norway, clinical studies consist of 90 ECTS credits, but for Sweden these encompass 45 ECTS credits. The directives 77/ 453/ECC of June 27, 1977 and 89/595/EEC of October 10, 1989 require that a preregistration programme should be at least 3 years or 4600 hours long, although these directives prescribe that the clinical studies should be 50%. However, there are certain differences in the interpretation and implementation of these directives in each of the four countries. There are also minor differences in the number of ECTS credits required for a Bachelors dissertation in Denmark, Finland, Norway and Sweden (Table 2). There are also differences concerning graduate diplomas and graduate diplomas in specialist nursing. In Finland and in Norway, specialist courses are allocated ECTS credits but are placed outside the Bologna system. In Denmark, specialist courses in paediatric nursing are a part of the rst cycle. All other specialization courses remain outside the Bologna system. In the second cycle, there are variations of between 60 and 120 ECTS credits in the length of studies and their content. In this cycle, all Scandinavian countries have different pathways up to Masters degrees. Students can acquire a Masters degree that equals 60, 90 or 120 ECTS credits. Furthermore, the programmes can be either clinically- or academicallyoriented. For example, in Sweden specialist nursing education is part of the second cycle. The degrees are also named differently, e.g. candidate degrees (Denmark 120 ECTS credits) and Masters degrees (between 60 and 120 ECTS credits in all Scandinavian countries). Furthermore, in Finland the term candidate refers to an academic degree in the rst cycle (180 ECTS credits). Thus, it is impossible to compare the content and level of different degrees in the Scandinavian countries based only on the name and title classications. Direct comparisons between pathways for further education are difcult to make as there are divergent requirements for entering the second cycle. After a Bachelors programme, students can enter the second cycle directly. The only exception is Sweden, where students need to have additional clinical experience before entering specialist nursing programmes (Table 3). In the third cycle, there are also differences. In Sweden a doctoral degree requires 120 ECTS credits, in Denmark and Norway 180 ECTS credits and in Finland 240 ECTS credits. In Finland and Sweden, postgraduate students may rst earn a licentiate degree in the third cycle before completing a full

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doctoral degree, but it is also possible to acquire a PhD directly without pursuing a licentiate degree rst. The licentiate degree is not an option in Denmark and Norway. For a nursing student to achieve a PhD degree, 510 ECTS credits are required in Denmark, 570 ECTS credits in Finland, 480 ECTS credits in Norway and 420 ECTS credits in Sweden (Table 3).

Author contributions
MBR, BLH, AL & AS were responsible for the study conception and design. MBR, BLH, AL & AS performed S performed the data the data collection. MBR, BLH, AL & A analysis. MBR was responsible for the drafting of the manuscript. MBR, BLH, AL & AS made critical revisions to the paper for important intellectual content. MBR, BLH, AL & AS supervised the study.

Conclusion
This discussion shows that there are problems and challenges concerning the harmonization process. There are different numbers of ECTS credits, content and names for degrees in nursing programmes in all cycles. It seems as if all policymakers in the Scandinavian countries have different ways of interpreting and implementing the Bologna Process. Although the ideal of worldwide standards for nurses promoted by the ICN for over a century remains unrealized, the forces of globalization have created impetus for change. Standards for nursing education need to be established globally to provide guidelines for local services, but also to assure a minimum standard level of qualications for nurse educators. The Bologna Process offers the opportunity to standardize nursing education, with the Bachelors degree as the entry level to the profession, and Masters and doctoral degrees recognized in all EU countries. The Tuning Educational Structures in Europe project builds on previous endeavours to enhance inter-university cooperation, and aims to identify generic and specic competencies for nursing graduates at all levels. Education has proved to be a valid instrument for building a common professional identity, and so it has been considered necessary in higher education to proceed via internationalization (student exchanges) towards active Europeanization. The goal of employability, in particular, is closely connected with the degree structure reform of the Bologna Process. Policymakers in nursing education need to consider more carefully the intentions in the Bologna Process in the planning and implementation of Bachelors level nurse education and in the pathways to further education.

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Funding
This research received no specic grant from any funding agency in the public, commercial, or not-for-prot sectors.

Conict of interest
No conict of interest has been declared by the authors.

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