Evolution of Nursing Education, Research and Practice: Insights to Foster Nurse Solidarity and Address Future Challenges

In celebration of the 50th anniversary of the Journal of Advanced Nursing, this commentary explores the evolution of nursing education, research and practice over the past five decades. In particular, we reflect on the key milestones, transformative innovations and pivotal developments that have shaped the profession, particularly during a period marked by rapid technological advancement, the growing burden of noncommunicable chronic diseases (NCDs), the global impact of the coronavirus disease 2019 (COVID-19) pandemic, and the challenges posed by ageing populations. Amid these transformations, the role of nurses has become increasingly vital. In every setting, our adaptability, resilience and commitment have been instrumental in maintaining the stability of the healthcare system. This commentary discusses how these four key milestones have shaped the nursing profession, influenced patient-centred care, developed nursing practices and nursing knowledge and increased the impact of nursing on global healthcare systems. This commentary will highlight the pivotal research, policy changes, and transformative shifts in nursing education and practice over the past half century and identify the major challenges that the nursing profession is likely to face over the coming decades. Central to this forward-looking perspective is the concept of solidarity—defined as unity and mutual support within a group—which we propose as a guiding principle for addressing future challenges in nursing. By fostering solidarity among nurses, healthcare professionals, and communities, we can strengthen our collective capacity to navigate the evolving landscape of global health. Nursing education, research and practice have undergone revolutionary changes following important milestones over the past 50 years, which have reshaped the nursing profession. The first part of this commentary delves into four pivotal areas: the transition to higher education, shifts towards specialisation and advanced practice, the impacts of pandemics, and an ageing population. Taken together, these milestones reflect the dynamic and progressive nature of nursing and underscore its vital role in healthcare. Until the mid-20th century, nurse training was primarily based on hospital apprenticeships focusing on practical, task-oriented skill development. In the past five decades, the transition from traditional apprenticeship-based training models to university-based education has created the foundation for a well-educated nursing workforce capable of managing the complexities of modern healthcare. In the 1980s, a transformative wave in university-based nursing education began in the United States and soon spread to other countries. This progression came in response to increasingly sophisticated healthcare needs that required a more educated workforce to meet the higher complexity of the healthcare system. In 1983, the Institute of Medicine in the US called for the creation of a national centre for nursing research and recommended that nursing research be integrated into practice to improve healthcare outcomes, in addition to increasing the numbers of university-educated nurses (National Institute of Nursing Research 2025). The report also suggests a new transformative wave to promote the value of teaching nursing in higher education. Around 1990, a key nursing initiative, Project 2000: A New Preparation for Practice, was launched in the UK to support the teaching of nursing, midwifery and health visiting practices throughout the educational system (Le Var 1997). Following Project 2000, the former apprenticeship model was replaced by baccalaureate and higher degree programmes in university-based education. Similar transitions were adopted in other Western countries, such as Canada and Australia. In Hong Kong, tertiary-level nursing education dates to the late 19th century, with its longstanding emphasis on high-quality foundational training and postgraduate specialisation. Over the years, the region has made significant strides in advancing nursing education, culminating in the establishment of the Bachelor of Nursing degree as the standard qualification for registered nurses. This shift reflects global trends towards university-based curricula and the professionalisation of nursing. Meanwhile, Mainland China—home to the world's largest nursing workforce—continues to expand its healthcare capacity and elevate educational standards through coordinated national initiatives (Wu 2023). This transformation from vocational training to formal nursing education in universities has marked the growing global solidarity in nursing education. Organisations such as the International Council of Nurses and the World Health Organisation (WHO) have facilitated knowledge sharing through publishing guidelines (e.g., WHO's Global Standards for Professional Nursing Education), enabling low-resource countries to adapt university-based models. Thus, the transition to university-based nursing education was successful. In April 2023, the results of the 2022 National Nursing Workforce Survey showed that the proportion of registered nurses with a bachelor's degree or higher in the US workforce exceeded 70% for the first time (American Association of Colleges of Nursing 2024). This is close to the Institute of Medicine's (2011) recommendation that 80% of the nursing workforce hold a bachelor's degree by 2020. Today, nurses are increasingly pursuing doctoral degrees (van Dongen et al. 2024), which will have a significant impact on future nursing care and patient outcomes. Most importantly, this transformation in nursing education has paved the way for nursing specialisation and advanced practice nursing (APN). As healthcare demands have evolved, the roles of nurses have also changed, resulting in the emergence of advanced practice nurses with specialised skills and knowledge (Bryant-Lukosius et al. 2004). These advanced practice nurses are expected to acquire higher and broader levels of competencies to assume specialised roles in the healthcare system. The concept of APN first emerged in the United States and Canada in the 1960s and gradually gained international recognition. The UK adopted this nursing concept during the 1970s, and it later spread to other countries. In 1994, the Hospital Authority of Hong Kong introduced the nurse specialist role, which was then reclassified in 2000 as an advanced practice nurse role. In 2009, the ranking position of nurse consultants was introduced to systematically enhance the impact of APN professionals in the healthcare system. Advanced practice nurses play multiple roles in the healthcare system, including providing evidence-based practice, leading education, performing consultations, initiating service development, supervising continuous quality assurance, and conducting research. Apart from their advanced clinical practice duties, they are also expected to play crucial roles in evidence-based research to inform nursing practices and healthcare reforms. Master's programmes in Nursing initially focused on advanced general practice. Over time, these postgraduate programmes began to offer supervised practice in speciality fields. Advanced practice nurses now serve to bridge healthcare disciplines, fostering interdisciplinary solidarity to improve patient outcomes, which further promotes the development of nursing specialisation and APN. Establishing institutional frameworks is essential to support and formalise these evolving roles. In 2011, the Hong Kong Academy of Nursing was established and immediately played an important role in creating systems to support APN. In particular, a statutory certification system was established to protect the safety of the public and to legitimise APN. In 2024, the institution was renamed the Hong Kong Academy of Nursing and Midwifery. Hong Kong's APN model aligns with global trends emphasising advanced clinical skills, leadership and specialist roles within nursing career progression. About 5000 advanced practice nurses are currently working in inpatient and specialised settings in Hong Kong, demonstrating competencies comparable to those of their international counterparts. Over the past 50 years, the global healthcare system has confronted two major pandemics, severe acute respiratory syndrome (SARS) and COVID-19, each leading to significant changes in the evolution of nursing practices and education. The SARS experience has prepared the nursing workforce for public health emergencies by strengthening infection control practices and crisis response strategies. For example, Thompson et al. (2004) advocated that nursing curricula be revised to strengthen the education of all healthcare professionals. The SARS pandemic also revealed the potential for innovation in nursing education, as technological advancements and the new knowledge produced by research and continuing education have played pivotal roles in the development of professional competencies in APN, including in leadership, organisational change, and evidence-based practice (Wright et al. 2024). Moreover, the COVID-19 pandemic had a profound impact on the mental well-being of the population. The sudden and overwhelming demand for skilled healthcare providers revealed both the resilience of nursing professionals and the vital importance of maintaining a robust, adaptable nursing workforce. This experience underscored the importance of preparing nurses not only with clinical expertise but also with emotional and psychological support to give them resilience to weather the high-pressure challenges of providing healthcare during global pandemics. In particular, offering psychological support for nursing professionals to protect their ongoing well-being within the complex requirements of modern healthcare environments became of paramount importance during the unprecedented challenges of the COVID-19 pandemic (Cheung et al. 2023). Hence, we now understand the importance of early interventions, such as providing individual and organisational support for nurses, including flexible scheduling and rest periods, to ensure the future readiness of the healthcare system. Consequently, the COVID-19 pandemic provided a pivotal moment for nurse practitioners and policymakers to reassess best practices in the healthcare system, including the safety and quality of patient care, in addition to their own needs (Smith et al. 2020). Nurse educators have also played crucial roles following the disruption of nursing education during the COVID-19 pandemic (Ion et al. 2021). In particular, nursing education quickly shifted from face-to-face teaching to adopting technological advancements in online and hybrid learning models to ensure that nursing students could continue their education despite lockdowns and social distancing measures during the pandemic. However, the impact of in-person clinical training was undermined. In response to this issue, nurse educators employed innovative teaching strategies to provide simulation- and virtual reality-based education to allow their students to complete their nursing education. Up to 50% of the required clinical hours were replaced by simulations during the pandemic (Martin et al. 2023). As more nursing students are now trained in universities, the COVID-19 pandemic also highlights the need to adapt flexible educational methods due to the limited learning opportunities in hospitals following pandemic restrictions. Simulations and other innovative methods can become alternatives to the tight schedules required for clinical placements. However, there are some considerations to address when incorporating simulations as a permanent component of the nursing curriculum, such as balancing the advantages of traditional clinical placements against the allocation of resources, faculty development, and curriculum development to ensure that nursing students gain empathetic, human-touch experiences with real patients. Additionally, the shift to online learning during the COVID-19 pandemic imposed tremendous stress on nursing students, raising concerns about their limited clinical practice opportunities, restricted physical classroom interactions with classmates, and potential graduation delays. From an organisational perspective, educational institutions must consider implementing strategies to support their future students' mental health and build resilience in cultivating their ability to manage the potential stressors of future pandemics. To enhance clinical reasoning skills both in school and at home, advanced technologies, such as online virtual simulations, have been adopted. During the COVID-19 pandemic, nursing researchers generated new knowledge to inform best practices. For example, they addressed immediate clinical challenges, such as the psychological impact of COVID-19 on healthcare workers (Lorente et al. 2021). Studies conducted among advanced practice nurses described their expanded roles and responsibilities during the pandemic, especially in the direct care of patients with COVID-19, individualised patient care and healthcare team support, which informed best practices and highlighted the importance of interdisciplinary and supportive environments (Chair et al. 2024). Overall, the robust and rapid research output during the COVID-19 pandemic has directly impacted and informed advanced practice nurses' future clinical practices, operational strategies, educational practices and policies (Choi et al. 2020). In particular, these new standards have laid the groundwork for an increasingly resilient and informed nursing profession in the future. Over the past five decades, population ageing has emerged as a major global concern, with profound social, economic, and health-related implications. According to the World Health Organization (WHO), global life expectancy at birth has risen from approximately 65 years in 1970 to over 73 years by 2024 (World Health Organization 2025). This demographic shift has significantly contributed to the rise in NCDs—including cardiovascular diseases, cancer, diabetes, and chronic respiratory conditions—which are now among the leading and largely preventable causes of morbidity and mortality worldwide (World Health Organization 2013). The growing prevalence of NCDs among older adults has placed considerable strain on healthcare systems, resulting in increased patient loads, more complex care needs, and heightened staffing pressures. These challenges contribute to elevated levels of nurse burnout and workforce turnover. Nursing education has had to rapidly adapt by integrating gerontology, NCD management, and palliative care into curricula, often stretching institutional resources. The demand for specialised geriatric care continues to outpace the supply of trained nurses and qualified educators, particularly in ageing-related fields. Moreover, the physical and emotional demands of elder care may deter students from pursuing careers in this area, further exacerbating workforce shortages. In considering the most significant developments, innovations and milestones in nursing education over the past half century in this commentary, we must ask what the key challenges that the nursing profession is likely to face over the next half century are and how we can address these challenges to meet our global population's future healthcare needs. In our ever-changing world, providing healthcare services has never been so complex. Therefore, this third part of our commentary aims to illuminate different aspects of the current and future challenges for nursing education and practice, such as the transformation of nursing education, nurturing the younger generations of nurses, technological advances (especially the evolution of artificial intelligence [AI]), nursing shortages and professionalism, and the implications of an ageing population. Following advances in healthcare technologies, increased medical knowledge, growing awareness of the public's to be emphasis on patient and and higher public of nursing nurses face more challenges Therefore, it is crucial to identify strategies to new generations of nursing professionals to face these challenges and within increasingly complex healthcare systems. 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