Undermining nursing care by degrees

The proposal that nurses in England should be university graduates will further reduce the level of basic nursing skills.

Ann Keen, the health minister and a former nurse, wants to raise the status of nursing and the quality of patient care. Others, like the main nursing union, the Royal College of Nursing (RCN), and the chief nursing officer, Dame Chris Beasley, want to make nursing more attractive and to get rid of the stigma of nurses being ‘doctors’ handmaidens’. And the proposed solution to this problem that Keen plans to consult on? All newly qualified nurses should be university graduates by 2013, up from the current level of 25 per cent.

Admirable sentiments, considering how bad things have become, if a damning report published by the Patients’ Association this year is to be believed (1). The report outlines the dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment that patients and their elderly relatives have experienced at the hands of some National Health Service (NHS) nurses.

A row of sorts has erupted in response, suggesting that the problems identified will not be addressed by degree-based training. As a nurse of 35 years standing, I wholeheartedly agree. I believe that the most fundamental aspect of nursing – caring – has been degraded and devalued. Bedside care has been devolved to health care assistants with registered nurses undertaking more technical tasks. It’s as if bedside care is no longer the remit of nurses.

But I don’t think it’s the role of universities to address this problem. Universities should not be used for instrumental purposes like teaching skills. Their role should be an entirely different one.

Nursing has been and remains for many, a poorly paid occupation, although huge variations as well as opportunities exist within it. In the past, we were bought off with platitudes like nursing being a ‘vocation’ and being ‘ministering angels’, as if we were nuns, not health workers. Although we partially colluded with this patronising and demeaning view of ourselves, we at least felt, despite our lowly status, that we were doing the job for altruistic reasons. We felt valued, respected and trusted by patients and the public alike. We felt that we did a good if hard job, and gained a lot of satisfaction from helping people.

Our professional organisations and trade unions didn’t ever put up much of a fight to change our pay or conditions, however. Some even actively discouraged us from seeing ourselves as ordinary members of the public-sector workforce. We were supposed to be different. We cared, unlike the porters and domestic staff who took strike action from time to time. All that’s changed, of course, as has the status of nurses – but not necessarily for the better in my estimation.

In wanting degree-based education for nurses, Keen and the RCN are presumably acknowledging that current nurse training is inadequate, at least as far as England is concerned. Nurse training in Wales is already degree-based. Prior to 1992, when diploma-level training was introduced, nurses spent only a quarter of their training in the classroom and three quarters on the wards. The supernumerary status that student nurses acquired in 1992 meant they were no longer part of the clinical workforce. They are now expected to learn through supervised participation – observing but not participating enough in the care that health care assistants and registered nurses perform.

It’s not surprising, therefore, whether graduating with degrees or not, that many nurses qualify with quite basic and superficial knowledge and with nothing like enough skills, knowledge, clinical and practical experience. Much of this then has to be learnt after qualifying; the time when they should be consolidating what’s been learnt, putting theory into practice and taking on new responsibilities and becoming good practitioners. Some never learn the skills adequately.

This invariably has a knock-on effect. Wards become staffed by poorly trained, inexperienced nurses not up to the job, who find basic nursing care challenging. The nurses who stick around and thrive, despite all of this, have to work under enormous pressure, trying to carry the load that their less-experienced colleagues can’t share (or even add to), struggling to keep the show on the road and maintain standards and trying to ensure that patients are cared for competently and compassionately. Patient care is consequently sometimes less than adequate. And the pressure this engenders contributes to many good nurses leaving the NHS.

But degree-level education is not the answer to the problem of inadequate training and poor care provision. Indeed, it may exacerbate it. As has been written about at length on spiked, degree-level education in Britain, in general, has long been inadequate and unchallenging for students and does many a disservice. It’s even been suggested that a degree is now the equivalent of the school exam for 16-year-olds, the GCSE, because the standard has dropped so low.

But universities should not be teaching skills anyway. Instead, they should be helping students expand their minds, teaching them to think and to acquire knowledge for knowledge’s sake. Leave skills training to the nursing colleges where it belongs.

The practical, attitudinal and compassionate skills that nurses need to acquire, so that they become intuitive in the provision of care, have to be learnt on the job. Theory ought to be after, not prior to actual experience. This practical side is the very aspect of training that nurses get an insufficient amount of already. The problem can only get worse if university-based training becomes the norm because the emphasis will shift further to theoretical aspects of caring as opposed to its practical application. That may well compound the existing prejudice about nurses being ‘too posh to wash’, delegating the work to less qualified health care assistants.

These fundamental problems need to be acknowledged and discussed before going any further with this consultation. Caring for sick people is a privilege and nurses need to be competent in providing it. When they are, their status will automatically improve. Nurses can and should be able to attend university after qualifying and when they’ve consolidated their knowledge and acquired the necessary nursing skills. Meanwhile Ann Keen and the RCN could review the seriously flawed ‘Agenda for Change’ they so enthusiastically support, to address the pay and conditions of nurses and other NHS staff.

Bríd Hehir is head of engagement and patient involvement and sessional nurse in the NHS in London. She writes in a personal capacity.

(1) Patients not numbers, people not statistics, Patients Association

This was first published here 17 Nov 2009