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What’s another year?

January 6, 2015

Another year, another NHS leader indulges in a bit of nurse-bashing. Speaking on the Today Programme this morning, Mike Proctor, former nurse turned Deputy Chief Executive of York Teaching Hospital NHS Foundation Trust, explained to John Humphrys why pressures on beds have led Scarborough Hospital to declare a major incident this week. Recruitment, he said, is his biggest headache. The doctors and nurses he needs in order to open and maintain extra bed capacity at the hospital ‘do not exist’. I’m with him so far.

It was what he said next that really got me shouting at the radio. Asked by Humphrys what steps could be taken to alleviate the problems, he replied that there were no quick fixes. He was, however, good enough to give us his ‘personal view’. Which was that ‘in terms of nurse education…we need to widen the entry gate…and focus on recruiting…away from the traditional eighteen-year olds with good ‘A’ levels…There are lots of people out there that are more mature, that are perhaps less academically gifted, that would make fantastic nurses and they would stay in nursing longer than the current group would’.

After last week, and the Daily Mail‘s serpentine attack on degree nurses, I didn’t really plan on returning to this subject again so soon. I’d hoped I could give it a rest for a bit. But the truth seems to be that as pressure on the NHS increases and and the scale of the recruitment crisis becomes ever more apparent, calls to make nurse education ‘less academic’ are being increasingly voiced. According to this logic, lowering the entry bar will open up nursing to more people. Problem solved.

OK, Mike – time for a reality check. The Willis Commission (2012) found that ‘the average age of a nursing student is 29’. The Royal College of Nursing (also 2012) found that people aged thirty and over formed that second-largest group of applicants for nursing courses in 2011. The shift away from your ‘traditional eighteen-year olds’ has already happened.

Secondly, where is your evidence that ‘the current group’ (by which I’m assuming you mean ‘nurses with degrees’) won’t stay in nursing? Are you saying that patient care is so unstimulating that only ‘less academically gifted’ people would be attracted to it as a career? Or are you saying that it’s just too much trouble to develop bright people so they’ll want to continue contributing to nursing? Easier to shrug your shoulders and let them take their talents elsewhere, huh? And all this before we’ve even touched on the evidence that better-educated nurses mean better patient outcomes. Nice one, Mike.

Given that Mike had made such a big thing of it, I was disappointed that John Humphrys chose not to put his suggestion about nurse education to the next interviewee – Health Secretary Jeremy Hunt. It would have been very interesting to hear what he had to say. But even without his contribution, the fact remains that those seeking easy explanations for the NHS crisis are becoming ever bolder about stating publicly that nurse education is to blame. What was even more interesting was the glimpse into the mindset of the big employers that Mike’s unguarded comments gave us. And on this showing, that mindset is one of deep frustration.

At the heart of this frustration is the fact that all UK undergraduate nursing courses are now heavily oversubscribed. Although we have now entered a period of modest increases in places, there remains a huge discrepancy between the numbers applying and the places available. To the employers, it looks like a criminal waste of talent that they could be using. Mike could plausibly argue that the comments he made on the Today Programme were directed as much at Health Education England (HEE – the body that commissions places on undergraduate courses in England) as at nurses themselves.

Which is why it was very interesting that the day after taken to the airwaves, the Nursing Times reported that Lancashire Teaching Hospitals NHS Foundation Trust had taken matters into its own hands and ‘helped to design the new University of Bolton [nursing] course…with all students accepted onto the programme offered a job at the trust after graduation’.

The article went on to explain that about fifty places would be on offer each year, divided into two cohorts. The big difference is that unlike places on other English nursing degrees, the Bolton scheme has been commissioned without input from HEE; these places are additional to those operated under the umbrella of the commissioning body. As such, students will not attract HEE funding for their studies, and will be expected to fund themselves through the student loans scheme. The first intake has six applicants for every place.

There is not, of course, any suggestion that what is on offer at Bolton is not a ‘proper’ degree; it boasts the standard 50/50 practice/theory split and its contents have had to satisfy Nursing and Midwifery Council regulations for undergraduate nursing courses. But the fact that an acute Trust has ‘helped to design’ it raises questions. It suggests that the Trust is attempting to tailor course teaching to its own particular requirements. For me, this sets alarm bells ringing.

Firstly, it sparks huge debate about the purpose of higher education: is it there simply to churn out people with skills dictated by industry; or is it a thing to be prized in its own right, a chance to develop one’s personal philosophy and independence of thought. And secondly – and more pragmatically – the course information states that all placements will be ‘within Lancashire Teaching Hospitals NHS Trust’. But this is a Trust that operates acute hospitals only. So just as Lord Willis is dropping heavy hints that his review of nurse education is going to recommend more integration of the various wings of the service, we’re getting a course that is specifically slanted towards the needs acute general hospital Trusts? Please tell me I’ve got this wrong.

As the staffing crisis deepens, we are going to see more initiatives like this one. I would go as far as to say that ‘imaginative ways with education’ is going to be one of the nursing stories of 2015. But it’s going to be about much more than who runs what; the nature of these new courses is going to spark debate about the soul of nursing in the twenty-first century. Academic discipline or vocational training? You heard it here first.

For more overheated ranting on this subject, see also my earlier post:

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  1. Basket Press permalink


    As one who had a degree BEFORE coming into nursing, back in the days when it was neither profitable nor popular to be a nurse with a degree, I can only emphasise the sheer stupidity of those who somehow equate having a degree with not be able to provide care. Why is a degree apparently a symbol of not being caring? Answers please…

    As healthcare as a whole has become more reliant on increasingly complex treatments and we move towards a greater need for evidence-based treatment, surely we need MORE well-educated clinicians capable of assessing evidence? Or does that only apply to traditional graduate clinical disciplines, like medicine or psychology? If so, why? Where are the calls for Mao-style barefoot doctors?

    It is my experience, having worked exclusively in teaching hospitals and trusts, that much of higher management appear to like the kudos which comes with that but don’t like allowing their clinical staff to actually engage in all the activities which come with that (for which trusts are paid!).

    As to why clinicians stay or leave…Well, I believe our noble leader will shortly be putting up a post of mine which touches on such things, like how trusts treat their staff…Which has nothing to do with their qualifications or lack of…

  2. Our noble leader?! You make me sound like Big Brother!

  3. RGN007 permalink

    It not that I am against nurses having degrees or that having a degree makes nurses less caring. As someone who was a nurse without a degree or A levels, or O levels when I left school I had no problem questioning the practice of those with degrees, especially medical degrees who often did seem slow in some areas of emotional intelligence. I was privileged to train in a hospital that was too small to have student nurses at all so we pupil nurses did everything we felt competent to do. I do not recall any incidents, even without technology to run a dozen or so intravenous infusions in perfect time.

    There is some kind of backwards logic going on, that people do seem to often get the impression that there appears to be a skew in that many perceived to be high intelligence seem to lack common sense. This is not a see-saw where when one goes up the other goes down, but perhaps we all have various intelligence continuum and the system is determined to only judge one of them. Those in education seem to pin a high level of compassion, common sense on those who have higher education but we do not seem to have any evidence that high achievers in education know how to treat patients or colleagues with more dignity and respect that those like myself who have struggled to achieve qualifications. I realise now I have some form of dyslexia or autistic trait (we need to accept more diversity afterall) that has given me “exam” blindness. This is not anxiety, I love exams and learning. I seem to know the answers in class, but do not always understand the perimeters of the questions to pass the test.

    I recall assuming a young man had learning disabilities one day, when I was in a queue in a chip shop somewhere in Yorkshire, the family before me had a youth struggling to pack a shopping back with their purchase. The mum was exasperated as she watched her offspring scatter and squash their meal. The young man appeared inept and needed support to leave the shop. I made comment to the person serving after the family left, that the mother had such handful since the young man struggled with such a simple task. The reply was that the young man I thought had learning difficulties actually had just gained 5 A* in his A levels. Ok, this is not a degree but this young man could likely get into a very desirable university.

    As a pupil nurse I questioned why I practised sterile technique each morning on a busy surgical ward, only to find that a group of doctors/surgeons a short while later would rip off my dressings without washing their hands or (then) wearing masks and breathe over everything and then pat the dressing back. I questioned why did no one seem to understand that the (then) “back” round was NOT to wash the lower back but to adjust the patients’ positions to prevent pressure sores. I was also ticked off by a nursing officer for being idealistic for trying to chat with a person with brain stem injury.

    I think education has yet to recognise that people have brains with or without a degree. I’d like to see another way into nursing accepted rather than excluding all individuals who may be lacking in one lexical area to express themselves capable of being good nurses.

  4. Hi RGN 007 – thanks for commenting. I was interested in your image of a continuum. Picture one where one end is ‘do-er’ and the other end is ‘thinker’ – you can probably guess which end I’m holding up! Does that mean nursing has no place for me? Certainly, when I hear people express opinions Mike Proctor’s, the message I hear is that academic people are not really wanted. So although you may feel that opening up nursing to candidates who do not have formal academic qualifications is the way forward, you may find that at the same time as they are attracted in, others feel pushed out. Does it matter if our talents are lost?

    As I indicated in the post, the staffing crisis may – arguably – put us in a position where the imperative to train many more people will consign the academic elements of nurse education to the back burner. And I think there is a case for wondering whether secretly, this is what employers have wanted all along. In the busy workplace, where everyone is under pressure to ‘get the job done’ and nothing else, people who ask too many questions can be seen as a bit of a nuisance.

    On the other hand, the very magnitude of the staffing crisis means that we have no choice but to look at new ways of solving it. With the Bolton scheme, we seem to have come up with an updated version of the old ‘hospital attached school of nursing’ model. I think we will undoubtedly see more of this, and while out-of-the-box thinking is to be encouraged, we need to be on our guard to ensure that the employer side of the partnership does not use it as a way to reduce or water down academic content just because they don’t see the need for employees to be academic or questioning – and may even prefer it if they are not.

    Personally, I don’t see much mileage in debating whether being academically-inclined automatically means that you lack ‘common sense’ or are incapable of compassion. I think we have to work with the recruits we have, do our best to identify their individual talents and develop them so that they make the best contribution they can. I take your points that there are many, many brilliant nurses who don’t have degrees, and that questioning practice is not the sole preserve of degree nurses – but here we are talking about the future of nursing – and that future is one of increasing complexity. My warning is simply this: don’t let the staffing crisis become the excuse for pushing nursing back into the past.

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