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Degree or Not Degree?: Why is it so hard to have a sensible conversation about nurse education?

August 24, 2013

I started my training in the mid-1980s. I had already been to university. There were times when I wished I hadn’t. Nurses without a higher education background viewed us graduates with suspicion and justified their prejudices by writing us off as ‘airy-fairy’, ‘too academic’, ‘too interested in talking to the patients’ (I kid you not) and of course – worst insult of all – ‘useless at the practical stuff’. Either that, or they expressed surprise when we didn’t conform to these stereotypes.

How times change. Nursing has just become become an all-graduate-entry profession and older health workers like me, whose first degree is in a non-health related discipline (or who, more likely, don’t have a degree at all) are now apparently a problem that needs to be rooted out. In June this year Peter Carter, General Secretary of the RCN, told the Nursing Standard that ‘poor care is much more likely to be delivered by nurses who are worn down and worn out’ and suggested that nurses who are ‘stuck in a rut’ should be offered the chance to change jobs and make a fresh start. The RCN’s formal response to the Francis Report, published in July, re-iterated this point when it said that ‘some nursing staff, particularly those who have worked in the system for a number of decades, eventually suffer from “care fatigue”’ and end up having their compassion ‘ground out of them’ (p29-30).

Even nurses whose more recent training rewarded them with a diploma rather than a degree seem to be in danger of falling victim to the bias towards degrees. Reluctant though I am to take issue with June Girvin, someone who has done so much to advance academic nursing in the UK, her recent statement in the Guardian Health Care Professionals Network that ‘the evidence clearly shows that graduate nurses offer better care than non-graduates’ must have dismayed many non-graduate nurses and left them wondering where they will fit in to the nursing landscape of the future. A nurse who responded to the article gave a possible hint when he or she confidently asserted that ‘the SEN [State Enrolled Nurse] role was replaced by the nursing DipHe which was stopped in the last 12 months’. This complete nonsense – the SEN qualification wasn’t replaced by anything; but in bracketing the diploma with the old (lower level) Enrolment, the writer leaves an unmistakeable pall of ‘second-class citizenship’ hanging over nurses without degrees.

If there is anyone out there who reads this blog regularly, they will know that I am a very committed supporter of university education for nurses. But that doesn’t mean I think that nurse training – or nursing students – are sacred cows that should never be criticised. If anything, I think the academic component of  pre-registration courses should be more demanding, more challenging.

The truth is that there are some superb nurses out there, who trained under a variety of different regimes. There are also nurses who sit at the desk all day writing notes and only engage with their patients during drug-round. And no, not all of them are washed-up old fifty-somethings who are just waiting out the time until they have amassed a large-enough pension pot to enable them to retire. Some of them are young. Some of them are students. What concerns me is is that within certain sections of nursing, acknowledgement of this fact has become un-sayable, a betrayal. This is unhealthy –  and was exemplified by Twitter reaction to an item in the Nursing Standard ‘Reflections’ section this week.

A ‘former nurse’ wrote about a frightening experience she had in hospital recently when a potentially life-threatening post-operative haemorrhage went unrecognised for several hours by junior nursing staff. The writer concluded that the switch to academic nurse education was to blame for this failing and advocated a new, longer, more hands-on training as the solution. OMG! Matron – the barricades! Somebody had the audacity to criticise nurse education! ‘Irresponsible’ said some; ‘not worth responding to’ said others. For goodness sake! A patient could have died! But…rather than empathising and admitting that something (even if only in this one isolated case) did indeed go horribly wrong, we seem to be more interested in stamping on the writer’s un-politically correct attitude to nurse education. Talk about own goal!

For a relatively arcane subject, nurse education attracts remarkably polarised opinions. The culprit, as I have argued in previous posts, is the popular media and its success in turning nurse education – though its equation of improved female education with a concomitant loss of caring faculties – into ‘a conduit for society’s disquiets about women.’ Nurses have inevitably reacted to this with a corresponding hardening of their own stance. So we are now in a position where to question the almost evangelical belief that no degree-educated nurse can ever, ever put a foot wrong is to be thrust into the arms of the nurse-bashing, Daily Mail-wielding, it-was-so-much-better-in-my-day, get-her-back-to-the-kitchen-sink brigade. Why is it not possible to say ‘yes, I believe in university education, but there are obviously still problems and we should examine ways to make things even better in future’? If self-critique is the hallmark of a mature discipline, nursing still seems to be at the potty-training stage.

For the record: my traditional, pre-project 2000 apprentice-style nurse training was, overall, pretty pants. The taught parts of it were mostly superficial and the placements were…variable, to say the least. When I qualified, I did not feel fully prepared for the staff nurse role. On the other hand, I do not particularly endorse  the view of the writer of the Nursing Standard piece that training courses should be extended to four years in order to incorporate much longer placement experiences. But I do acknowledge the unnecessary anxiety she was forced to endure as a patient, am sorry for it, and think it is right to ask why it happened. And I do support her right to voice her opinions. The academic project in nursing is only going to succeed if, rather than silencing or dismissing them, those of us who champion it actively engage with our critics.

I don’t expect this post is going to win me any friends; it might even make me some high profile enemies. I’m braced for some disgruntled ‘unfollows’, believe me. But it’s what I think, so I don’t see why I shouldn’t say it. Courage is one of the 6Cs, isn’t it?

For the RCN’s formal response to the Francis Report, see

For June Girvin’s Guardian article (with comments) see

For an heartfelt blog post on how a diploma nurse reacted to June Girvin’s article, see

For the Nursing Standard ‘Reflections’ piece (subscription only) see or Huddleson, B (2013): Extend Nurse Training. Nursing Standard; 27;51; p 26-27

For Quality with Compassion: the Future of Nursing Education (aka The Willis Commission) (2012), which found current nurse education fit for  purpose, see

  1. June G permalink

    I don’t disagree with you for the most part, and the points you make are constructive and helpful to the debate – although, I think like you, I wish it was a debate we didn’t have to keep having. My strong views are less about a nursing degree and more about the importance of ‘graduate’ skills, and it is the antipathy to this that I find most frustrating.

    I don’t know what your first degree is in, but I guess that the study skills and critical thinking skills you gained are what help to make you a better nurse. I don’t denigrate nurses without a degree – I don’t have a nursing undergraduate degree myself – I did a Masters degree in my forties – but I do believe that continuing one”s education and stretching one’s intellectual capacity is what increases our capability to be better at whatever we do. There is evidence to show that graduate nurses lead to improved outcomes – I’m sure you can look at the literature for yourself – and that should be sufficient for us to at least explore increasing the ratios.

    I worry about the notion of nurses without degrees seeing themselves as ‘second class’ in some way. And I think that there is much that employers need to do to ensure that they don’t confuse academic qualifications with hierarchy – this is currently a particular problem in the NHS and I think it needs attention. Track record and being able to demonstrate your ability to fulfil and exceed role expectations are much important to me when I am interviewing. Academic qualifications can only ever be a proxy for competence, not a guarantee.

    I think we are on the same page here, just different handwriting maybe. I hope this is a sensible discussion about nurse education.

  2. Thank you very much for leaving a comment. Like you, I am concerned that nurses who do not have degrees are going to get left behind. Many of the best nurses I have ever met started out as SENs and then converted to RN. In future, I think we may see something similar with diploma nurses converting to degree.
    I also agree that people often don’t ‘come of age’ academically until they are older. I did a Master’s when I was in my thirties and it was in many ways a much better experience than my first degree. So yes, it’a important to be clear that it isn’t ‘all up’ when you finish your initial qualification.
    But it’s the same with education in the abstract. My bigger point with this piece was that it’s important not to feel that just because nurse education is now all-degree, it is suddenly beyond criticism. Yes, the battle was hard-fought, but now it’s won, we cannot rest on our laurels. This is the begining, not the end!

  3. I have always been in favour of educated nurses. My own experience was one of an apprenticeship-style training (qualified in July 1980) which I later followed up with a nursing degree. I actually felt very well prepared for my staff nurse role on a cardio-thoracic surgical ward, having often been in charge of wards at night on becoming a second-year student, and frequently on day shifts as a 3rd year student. Indeed, I expected – and wanted – to be in charge as a newly-qualified nurse and, whilst it was stressful in the first 2-3 months, one soon became confident and increasingly competent – that is to say, competent at the level of a newly-qualified nurse. It also showed me that I needed to have more theoretical underpinning and, within the first 6 months of qualifying, I applied to do an ITU course, which I started the following January.

    My nursing degree did not teach me to be a better nurse with respect to basic practical care. That was what I learnt during my apprenticeship. In my opinion, practical care is something that is best learnt in the workplace, with real patients, alongside good role models and supervision. You can be taught the theory, and a certain amount of practise can be done on models, but you have to hone your skills on real people. After all, nursing is a practical job.

    I am deeply concerned that newly-qualified nurses today do not feel ready for clinical practice. Their education and training should equip them for the role of a staff nurse, ready and willing to take charge of a clinical area, albeit feeling apprehensive. When people take their driving test, they are being tested for their ability to go solo. If they pass, it is expected that they will be in the driving seat from day 1. It is scary driving alone for the first time, but people don’t take their test and then refuse to drive. I think this is an analogous situation to a nurse passing finals. If nursing students do not feel prepared for their future role after they have graduated, then their course has failed them. If the educational system is working well, then we need to look beyond it. What is happening in the workplace that allows newly-qualified staff to remain mentally prepared as “students”?

    The question isn’t about whether nurses are “better” if they are graduates – that is a fatuous argument. What is much more fundamental is, what does it mean to be a nurse in the 21st Century? And, what then do nursing students need to learn in order to be equipped for their role on completion of their education? Once we answer these questions, the “how” becomes evident.

    Nursing is not a coherent profession. Nurses still want to take on the work that other professionals have traditionally done – what was once known as the “extended role”. Any other health professional is very clear about what they do and don’t do – the boundaries of their role. Nurses are the one professional group that actively seek to acquire new skills that are traditionally done by another professional group – e.g. phlebotomy, surgical assistant, endoscopy.

    Furthermore, what I took for granted as the core of my professional role, that of administering “basic nursing care”, is now deemed to be the province of the Health Care Assistant. If this is not nursing, then what is? Until we are clear on what it means to be a nurse, have strong nurse leadership and stop trying to be another professional group, then we will continue to do a huge disservice to nursing. Graduate or not is irrelevant if we don’t have clarity of purpose.

  4. Thank you for your comments. A theme I keep returning to in my blog is that nursing doesn’t know what it is. This is not a new problem. Over at ‘The Radical Nurses Archive’, you will soon see that they were having heated debates about it in the 1980s! The difference is that then, the discussion centred on how much of traditional doctors’ work nurses should take on; now, nurses are handing over their core ‘direct care’ to health care support workers at a gathering pace. The Cavendish Review makes this very clear, and it is exactly the kind of issue that academic preparation needs to address.
    I agree that having a degree won’t help you to be a better practical nurse. That is down to personal qualities to some extent but mostly to quality of placement – and this is still far too variable. I think mentors need a lot more help than they get and it’s an area where change is overdue.

  5. For most of my student in nurse ‘training’ (if you can call it that) I felt like a dog hanging round a table looking for scraps from my ‘mentors’ and ‘supervisors’. After three years of sniffing about I was ‘qualified’ and then let loose on the unsuspecting public. Having previously completed a very good degree from a fine university, I was shocked at the cobbled-together nature of the training and would sit at the back of the lecture theatre with a bemused smile, sometimes squirming at the New Labour-ness of it all. I manage to survive ‘qualification’ but have frequently considered myself to be largely self-taught at times. It’s mostly through my own initiative that I consider myself a reasonably competent nurse. However, it should never have been this way.

    You could quite easily, and cheaply, train a competent first level nurse, or HCA, over a period of about 15 months. You would start them on a commensurate salary (Band 4.5) for the first year after qualification. Then depending on attitude and aptitude, that nurse could undertake further competencies/ training on the job in defined stages, their salary band increasing accordingly as they take on more senior roles such as managing a ward, IV drug administration and other more skilled roles. Those who don’t show aptitude or choose not to continue would remain as basic level nurses. If nurses wanted to gain some academic muscle later on this would be possible and would be properly encouraged and supported as being important to a senior role and service improvement, not something you grudgingly do on your own time unpaid. The important point being that nobody would be taking on tasks at any stage that they are not qualified for or competent to do. In this utopia there would be no role for new entrants with degrees and varying attitudes to hands-on care, whether that is actually the case in reality or not. It would be a gradual and managed apprenticeship, as happens in the UK’s best industries. Those nurses, who initially failed to get the A levels to get into medical school before falling back on nursing and who then subsequently decide they want to be endoscopists or minor surgeons, would be encouraged to go and train to be physicians assistants instead.

    Please beware, the Cavendish review is not a serious review by any objective standard. Camilla Cavendish is a relatively junior Times newspaper journalist who has long supported the Cameron/Hunt NHS privatisation agenda. This aims to run down NHS services to the point where privatisation becomes the more acceptable option to public. Nurses, much like ‘benefits scroungers’ and ‘bloody immigrants taking all our jobs’, are merely being used as scapegoats to facilitate this insidious agenda. Some privatisation and extension of secondary health insurance is both necessary and inevitable, but the North Staffs scandal was principally a crisis of under funding, under-staffing, bad management and structural neglect, not one of nurse education, no matter how bad that has been at times.

  6. Thank you for joining the debate. To turn first to your comments about the Cavendish Review – I know it wasn’t peer-reviewed research, but it did draw heavily on ‘proper’ research by Prof Ian Kessler et al (link at bottom of either of my pieces on the Cavendish Review). The Review’s conclusion that Health Care Support Workers now carry out the bulk of the ‘hands-on’ care reflects my personal experience, and, I should think, that of many others. Cavendish also flagged up the fact that many tasks that only a few years ago were the sole preserve of registered practitioners and now carried out by HCSWs. The RCN – with justification – seized on this as ammunition for its ‘HCSW registration/regulation’ campaign. But what is less remarked is that fact that these tasks used to be the sole preserve of individuals who were paid at registered practitioner rate. Now they are done by individuals who are paid much less, so to that extent, yes, HCSWs are being used as a political tool to drive down costs.
    Your scheme to give everyone the same basic on-the-job training with people progressing up the scale as they felt able and in line with their personal aptitudes would address this situation by clarifying everyone’s role and rewarding them with the pay commensurate to it, so I can see some definite merits. Your larger point however, seems to be that nursing is a hands-on, practical job that does not really require a university education in order to be done well. Certainly, this used to be true. but is it really true any more, if nurses don’t actually do much of the hands-on practical care…? Or maybe they should get back to doing more of it, because, after all, that’s what nursing really is, isn’t it?
    Again, we are back to the problem of conceptualisation. And actually, that’s why I think we do need need academic formation in nursing. How can we be nurses if we haven’t even asked the question ‘what is nursing?’ and tried to come up with an answer. And although of course it might be different in other places, I am concerned that the newly qualified nurses I speak to tell me that their
    degree-level education did not encourage them to consider problems like this.
    I am in favour of nursing degrees precisely because they give us the opportunity to engage with the big questions in nursing and health care generally. Whether that opportunity is being fully grasped in nurse education right now is open to debate, I think, and I would welcome contributions from those who are training at the moment. On the other hand, I am willing to admit that the consolations of philosophy probably don’t extend to filling in your twentieth social services referral this week and finding someone to cover on nights after your bank nurse cancelled at the last minute.

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