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Academic Nursing: Who needs Nursing Experts if anyone can be an Expert Nurse?

April 8, 2013

There’s blood on the carpet. Across the impeccably-upholstered research papers and deep-pile reference lists of one of nursing’s most respected journals, an ugly street-fight is raging. And it’s getting dirty. The opening salvo in this ferocious exchange came in the grenade-like form of an editorial lobbed into the pages of the Journal of Advanced Nursing in January this year. In it, Professor David R Thompson of the Australian Catholic University, Melbourne, and Professor Philip Darbyshire of Monash University, Melbourne excoriated the state of academic nursing in Australia and the UK in the most unambiguous language imaginable: university departments in both countries are dominated, in their view, by a ‘killer elite’ – a small but influential group of ‘mandarins of mediocrity’ who ‘dispense their perceived wisdom while not overly encumbered by any obvious academic talent’ and preside over ‘fiefdoms’ that are ‘critique-free zones, virtually devoid of any spirit of inquiry, ethos of debate or culture of scholarship’. To this state of affairs is directly attributable a ‘general decline in academic nursing, particularly in the UK’.

The backlash, as one might expect, was similarly vitriolic. In the May 2013 edition of the journal, Ann Gallagher, of the University of Surrey, lambasted Thompson and Darbyshire as ‘callous’, ‘myopic’, ‘destructive’ and ‘inflict[ing] horizontal violence’ while Rosamund Bryar et al described them as ‘judgemental’, ‘anecdotal’ and ‘disrespectful’ and observed that ‘the damage inflicted by the so-called ‘killer elite’ is negligible compared with that resulting from swingeing financial cuts from both Strategic Health Authorities and universities over the past five years’. The professorial duo responded by returning to the attack. Bryar et al were derided for providing insufficient evidence to support their counter-arguments and Gallagher was sarcastically dismissed as ‘wearyingly predictable’ and ‘disingenuous if not naïve’. Meanwhile, they commended their own position as ‘rare and far-sighted’.

Grumbling Appendix has not walked the Groves of Academe these many years, and so is unable to contextualise the current spat within a framework of recent personal experience. But what is certain is that applied nursing research does appear to be in the throes of some kind of crisis. Witness, if you will, some of the main points relevant to nursing in Patients First and Foremost (2013), the government’s initial response to the Francis Report.

Firstly, hourly (or intentional) rounding. Patients First and Foremost urges any hospital which has not already implemented this to do so within a year. But as Paul Snelling (2013) has recently demonstrated in a jaw-dropping critique, reliable evidence to support the idea that hourly rounding improves patient outcomes simply does not exist. I’ll repeat that: it simply does not exist.

Secondly, the move to require student nurses to work as Health Care Support Workers for up to a year as a precondition to securing a bursary for full nurse training. No one appears to know whether this concession to the view that university-educated nurses are ‘too post to wash’ will indeed disabuse potential candidates of their alleged over-mighty self-image. Supportive research findings have not certainly not been cited as a reason for trying it. But pending a pilot study, it’s about to become standard practice.

Thirdly, minimum staffing levels. On this, there is some (admittedly not completely clear-cut) evidence to show that mandatory minimum staffing levels would go some way towards improving outcomes. But the government has rejected it, at least as national policy.

Nursing in Britain established itself as an academic university discipline more than twenty years ago. Twenty years should be enough time, you would think, to achieve a critical mass of insight into what works in patient care and what doesn’t. Which raises the question of why, in the wake of the most damning assessment in living memory, are we turning for ideas on improving our performance not to eminent professors with proven track records in the field, not to peer-reviewed research – but to prime-ministerial hunch (David Cameron has gone on record as a supporter of intentional rounding) and populist bandwagons? Where are our intellectual pace-setters? How have we allowed people who have no specialist knowledge of nursing to hijack the debate and set the agenda?

Part of the problem is that, egged on by the media, the public has never really bought the idea that nursing is an academic subject. Nursing, according to this logic, is basically a common-sense hands-on activity that doesn’t require much in the way of intellectual investment. Sexist? Maybe. But anyway it’s an attitude exemplified by David Cameron. During a visit to a hospital in Salford in January 2012 he declared that hourly nursing rounds ‘decreased the number of falls and bed sore complaints by patients and put hospital infections at “rock bottom”‘. By failing to challenge this kind of statement, nurse academics might as well be signing their own redundancy notices. After all, who needs nursing experts if anyone can be an expert nurse? As has been admirably demonstrated by Snelling (op cit), none of Cameron’s assertions is backed by credible evidence. On the other hand, you can’t really blame the Prime Minister for feeling himself to be at liberty to hold forth about nursing: after all, academic nursing doesn’t even seem to have convinced its own offspring.

A quick trawl of research papers quickly confirms that in just one example of many, Forsman et al (2010) identified a large ‘theory-practice gap’ amongst graduate nurses. In their study, 54.9% registered nurses were found to be ‘low-users’ of research by the time they had been qualified for two years. Examination of the reasons for what the investigators themselves describe as an ‘alarming’ level of research usage did not fall within the remit of the paper, but the authors speculate that, amongst other factors ‘if recent graduates encounter clinical practice that does not correspond with demands for evidence-based nursing care, and if nurses fail to retain values from their education (assuming that they have acquired such values), their use of research may deteriorate over time’. In other words: it’s the culture, innit? We’re right back to the Francis Report.

The ‘big message’ of the Francis Report (2013), at least as far as nursing was concerned, was that there needs to be a ‘focus on the culture of caring’ (recommendation 185). The recipe for achieving this included strong leadership, aptitude tests for potential recruits and compulsory service in a caring capacity, registration for Health Care Support Workers. Some of these ideas have been accepted by the government, others have not. One thing Francis nowhere suggests is looking at measures to promote a culture that encompasses an emphasis on caring through an engagement with research. This is a missed opportunity of epic proportions.

The so-called ‘theory-practice gap’ is not a new discovery. It has been a commonplace of nursing discourse for years. What is really depressing, however, is that shifting nurse education into universities does not seem to have done that much to narrow it. The enormous number of learned journals packed with papers from the four corners of the world provide evidence in themselves that shortage of research is not the problem (although the quality is something others may wish to debate): the sticking point is getting nurses to incorporate it into their everyday practice.

So what would a Francis Report recommendation on making research a daily reality have looked like? Setting aside the inevitable chorus of protests (from both sides) about lack of time and resources, how about (just off the top of my head) more integration between clinical areas and universities – I personally haven’t seen an academic on a ward for years; lecturers ‘buddying up’ with wards; research link nurses; research-into-practice facilitators to help clinical areas choose and implement appropriate reasearch-based changes; more opportunities for nurses to participate in nursing research; protected time for monthly journal clubs; prospective ward managers to demonstrate at interview a proven interest in either conducting research or applying research findings. All these ideas would of course, only be acted upon subject to evidence-based proof of their effectiveness at driving change in the desired direction!

One is tempted to wonder if the reason why Robert Francis, in his Report, did not pay more attention to the potential of nursing research as a lever for improving nursing outcomes was because he unconsciously shared the populist belief that ‘academic nursing’ is a contradiction in terms. If, after all these years, nursing has still not been able to rid itself of this damaging prejudice, then maybe Thompson and Darbyshire are right. Maybe it is time to look at what is happening right at the very top.

Bryar R, et al (2013): Comment on: Thompson D R and Darbyshire P (2013) Is Academic Nursing Being Sabotaged by its own Killer Elite? Journal of Advanced Nursing; 69 (5). 1210-1211

Department of Health (2013): Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; London; The Stationary Office. Available to download at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/170701/Patients_First_and_Foremost.pdf

Forsman H et al (2010): Use of Research by Nurses in their First Two Years after Graduating; Journal of Advanced Nursing. 66 (4). 878-890

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

Gallagher A (2013): Comment on: Thompson D R and Darbyshire P (2013) Is Academic Nursing Being Sabotaged by its own Killer Elite? Journal of Advanced Nursing; 69 (5). 1211-1212

Snelling P (2013): Ethical and Professional Concerns in Research Utilisation: Intentional Rounding in the United Kingdom. Nursing Ethics; 20 (2).1-14

Thompson D R and Darbyshire P (2013) (1): Is Academic Nursing Being Sabotaged by its own Killer Elite? Journal of Advanced Nursing. 69 (1) 1-3. Now viewable online at: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2012.06108.x/full?utm_content=buffer4ca04&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer

Thompson D R and Darbyshire P (2013) (2): Comment On: Is Academic Nursing Being Sabotaged by its own Killer Elite? Journal of Advanced Nursing; 69 (5) 1216-1219

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