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The Apprentice – you’re hired!

May 6, 2014

In his introduction to Health Education England’s ‘refreshed mandate’ for 2014-2015, Dr Dan Poulter, Parliamentary Under-Secretary of State for Health does a very clever thing. Cloaking himself in the unlikely garb of good old-fashioned class warrior, he rousingly proclaims that ‘we must ensure that more progress is made in supporting people from poorer socio-economic backgrounds to enter medical and healthcare careers. This must include helping care assistants and healthcare support workers to break through glass ceilings and to progress into nursing and midwifery careers’.

Framing the ‘nursing apprenticeship-degree’ initiative – unveiled during National Apprenticeships Week in March and tentatively included in the refreshed mandate – in the language of social justice is an astute manoeuvre on the part of Dr Poulter. Nursing leaders who object that the idea risks ‘dumbing down’ nurse education and diminishing hard-won professional status can be portrayed, by this logic, as snobbish elitists whose whose romantic attachment to an academic ideal stymies social mobility and crushes dreams.

Of course all the rhetoric is actually just for show: the real impetus behind the new push to widen access to nursing courses is panic over the ‘ticking time bomb’ of impending nurse shortages. The situation is indeed grave. A report last year by the Centre for Workforce Intelligence estimated that the NHS overall was likely to be short of around 47,500 nurses as soon as 2016.  Against a backdrop of tightening immigration controls for non-EU nationals (and maybe EU nationals too if a future membership referendum results in the UK leaving Europe), recruitment from abroad is becoming more difficult. Closer to home, the Council of Deans recently warned that despite huge demand for undergraduate nursing courses, some higher education institutions could pull out of providing them altogether because cuts in funding are making them uneconomic to run. In this context, it seems quite sensible to eye up as the way out of the crisis a pool of workers who have already have a demonstrable commitment to care work.

But let’s be clear about something else too: this is a profoundly opportunistic move on the part of those organisations – dubbed ‘trailblazers’ by the government – who want to set it up. They include three Foundation Trusts and three private healthcare providers. Because while it’s true that whatever courses emerge from this will have to be delivered by a Nursing and Midwifery Council-approved learning centre and conform to the mandatory 50:50 theory:practice split, you can bet your butt the graduates they produce will be a new breed.

Not for them, I’m guessing, the usual post-registration add-ons of intravenous drug administration, cannulation and venepuncture, male catheterisation, care of central lines. Why? Because they’ll already have all these skills when they qualify. They’ll hit the ground running; it’s what employers want, and with the advent of the apprenticeship scheme it’s what they’ll seize their chance to get. If you’re a lecturer reading this, you’d better sit up and take notice – healthcare employers are sending you a message and it’s a blunt one: current degree courses don’t meet our requirements and we’re gonna take matters into our own hands to sort it out. You think I’m joking? I’m not joking.

What we could see next is nothing less than a battle for nursing’s soul. On the one hand, an academic conceptualisation based on traditional higher-education values of critical thought and analysis and within a liberal frame of reference. On the other, a narrower definition – pragmatic, outcomes-focussed and tightly tailored to the needs of the eventual employer, with the emphasis firmly on skills acquisition and a theoretical content largely related to that. Which route would serve nursing best?

This question is a crucial one – not just for nursing, but for other occupations too – because it asks, in essence, what is the purpose of education? Is it about the development of the individual by exposing him or her to broad channels of thought and encouraging opinion and expression? Or is it about equipping the individual with skills that enable the employer to conduct their business as smoothly and efficiently as possible? For a healthcare environment that is increasingly turning to the world of business for its inspiration, the second model certainly seems a better fit.

Being nurses though, we also have to ask which is the better model for patients. At first glance, the second one might look like the one to go for, especially if it facilitates expeditious diagnosis and treatment, shorter hospital stays and better outcomes. But despite much trumpeting – in the official press release that accompanied the launch of the apprenticeship project – of its potential ‘to make the NHS more compassionate’, questions remain. How do human qualities of care and empathy fit in when focus is heavily orientated towards the mechanics of process and throughput? Does it risk reducing patients to mere ‘units’? Does a liberal education in itself promote moral behaviour? And if we sacrificed it, what else might be lost at the same time?

Critics of the apprenticeship have warned that it risks dividing nursing by resurrecting the old Registered Nurse/Enrolled Nurse two-tier system of the past. I don’t buy it. Even today, nursing culture tends to be a place where practical know-how is prized above academic brilliance, and if the apprentice-graduates show themselves to be experts here, they will be both  sought-after and admired. No. The truth is that this scheme is likely to stand or fall on one thing and one thing only: money.

The state of student finances is truly scandalous. Recently, student blog after student blog has catalogued such manifold indignities as penury so severe it led to physical illness, selling treasured possessions (or just non-essential possessions), going without food, not turning on the heating, giving up independent living and moving back in with mum and dad. If the apprenticeship offers a wage, it’s going to look very attractive compared to this. The more so if all would-be students will anyway be expected to work as Health Care Assistants before commencing their course. If you’re already working as a HCA, and you’ve got the opportunity to join an apprenticeship, why not just do it? You’ll still get where you want to go, and you might suffer a lot less hardship along the way. Sure, at some future point you might have to top up to an honours degree at your own expense, but you can worry about that one later. No-brainer.

Regular readers will know that I did my training in the 1980s. Nursing degrees existed in those days, but they were pursued by a small minority; most students took the apprenticeship route. There are still many unanswered questions, but if this new scheme takes off, we could, within a few years, be right back to where we were then – with the addition of the foundation degree. The pity is that this change will have come about not through upfront debate within the profession, but through the tradesman’s entrance: market forces.

47,500 nurses is an awful lot to find. Plenty of HCAs are ready and willing. Opposition is the mark of the reactionary. If academic departments want to continue in the driving seat of nurse education, they might just need to gear up for the fight of their lives.

For the original Department for Business, Innovation and Skills press release about nursing apprenticeships, see:

For Health Education England’s ‘refreshed mandate’ for 2014/2015, see:

For a Nursing Times article on the predicted shortage of registered nurses, see:

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