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Bring Back Bagpuss!

March 19, 2015

Anyone else remember cult comedy series Dead Ringers from about ten years back? In one regular sketch, an irascible Michael Caine/Greg Dyke character (Dyke was Director-General of the BBC at the time) used to say things like “Bring back Bagpuss? All right. But don’t expect the mice to be in it. They’ve blown the bloody doors off my cheese stash once too often!”

Television of yesteryear is not, of course, the only thing to impart a warm, nostalgic glow. The nursing world now boasts its own Peter Carter/Norman Lamb/Nigel Farage mash-up, speaking with one voice that the route to salvation is via the resurrection of Enrolled Nurses (ENs). Earlier this month, Lamb (a Lib Dem and Coalition Minister for Care and Support) revealed to a symposium on residential care that he and outgoing RCN General Secretary Peter Carter are both ‘very attracted’ to bringing back a role ‘akin’ to the EN. Farage’s UK Independence Party (UKIP), meanwhile, has made their return a campaign pledge for the upcoming election.

On the Nursing Times website, most below-the-line reaction to this was somewhere on a continuum ranging from the mildly positive to the practically incontinent with happiness. “Should not have got rid of them in the first place” thundered Anonymous 11.16am in a response typical of the more hysterical end of the spectrum. “[I] worked with some that were far better nurses than some of the RNs I encountered”.

In my experience, that’s far from impossible. But it does raise the question of why, if ENs were so brilliant (and many of them proved they were just that by becoming highly respected leaders after converting to RN), they were shunted into what was, in effect, a dead-end qualification that bestowed no prospect of career progression? What does that tell us about the value we placed on them and the work they did? Not to mention nursing’s (in)ability to spot potential and manage talent?

More sinister still is the subtext that caring is inimical to ambition. (The misty-eyed nostalgists’ view of ENs is that they were primarily ‘bedside nurses’; others remember them as cheap labour who could take charge of the ward when it suited.) To this extent, the ever-louder noises-off about the revival of the EN are shreikingly dangerous. Why? Because holding up the example of the humble but devoted ‘real nurse’ would not only sow division within the profession, but even worse, would represent a deeply depressing victory for ugly media stereotyping of ‘uncaring’ career nurses. At a time when, more than ever, nursing needs to be clear that educated nurses are caring nurses, the revival of the EN would blur that message. And in doing so, it could seriously derail nursing’s future development.

To its credit, Lord Willis’s recent report on nurse education, Raising the Bar, rejects the creation of a modernised EN role. But despite its many positives (some of which I hope to discuss in future blogs), this is nonetheless a document permeated with desperation – verging on panic – about the acute shortage of nurses. The solution it offers is to make it easier for people who already work as health care assistants (HCAs) to embark on full-scale nursing degrees.

Along with pharmacists, health care assistants are currently being eyed-up by policy-makers as one of the few staff groups within the health system whose potential has yet to be fully exploited. Raising the Bar proposes two possible career pathways. Firstly, it’s suggested that HCAs could develop their competencies within the role they already have, to an intermediate or ‘bridging’ level probably set at Agenda for Change (AfC) Band Three. (I should say at this point that it’s far from clear how this new group would interact with Assistant Practitioners already working at AfC Band Four. On the face of it, it’s a recipe for confusion and possibly an excuse for downbanding).

Secondly, as described above, employers should be encouraged ‘to reduce barriers and…understand the strong benefits of developing a ‘grow your own’ model of nurses’ (p 40) – progress their HCAs into nurse education, in other words. The challenge for nursing as a whole is to balance the legitimate career aspirations of our many fantastic HCAs with the absolute imperative of not diluting the academic rigour of nursing degrees.

For this reason, I have concerns about the idea that experienced HCAs could complete a nursing degree in a mere eighteen months. I cannot see how many years maybe spent in a single environment, possibly picking up bad habits and with few real challenges, can equate to a properly muscular university- level education. This is not about the calibre of potential students; it’s about the value of the degree they will emerge with and the kind of nurses it will equip them to be.

So yes, we need more nurses. But that shouldn’t be a reason to give up on the constant fight to maintain our status as a degree-only profession. The Daily Mail ‘s long campaign of opposition to nursing degrees as an ‘acceptable’ proxy for opposition to career women generally tells you all you need to know about public attitudes to nursing – and by extension, women – that persist to this day. Unlike the ENs of fifty years ago, no one with ability who wants to progress in nursing should be prevented from doing just that. But the answer is not to lower the bar. To care, to lead, to innovate, to stand tall and ensure our voices are heard, we need our academic formation to be the best of the best. Unlike Bagpuss, let’s not get caught sleeping on the job.

  1. pennyhaswell permalink

    Bravo, very well said! Having worked as an SRN with SENs and being involved as a Nurse Tutor in their training, I am only too aware of the frustration that many of them felt at the limitations of the qualification. How they were often expected, in their view, to do much the same work as the SRNs but with less pay and much less kudos. How many of them had been pushed into doing SEN because they were’t confident enough in their academic skills or thought that two years was a better time to commit to than three; how many of them regretted those decisions afterwards and how many of them were sorely disappointed about the advice given to them, if not down right bitter.

    Why is it that patients/people are prepared to say that they’d rather see a consultant or the best qualified doctor but seem happy to have their nursing care given by anyone? Until they actually experience the benefits of a well qualified, experienced nurse – then the situation changes. Specialist nurses e.g. Breast Care, Stoma Care, Macmillan, nurses are all held in high regard but with little understanding of the academic path taken to get there. How will the new equivalent of the SEN accept those roles being out of bounds – or will they be…?

    It is essential that all nurses are trained to the highest degree and that that academic rigour continues during the career – every patient, whatever age, race, creed, gender has the right to expect that his/her nurse is truly well versed and up to date.

    I spent discussing ‘vocation’ or ‘job’, during my career, I was lucky in that I had a job I loved – when I was allowed to do it – but it was never a vocation. I regret to say I think I see the remnants of the old ideas that nurses are ‘angels’ who neither need nor want training or pay. How many years on since Sarah Gamp are we and we are still a coat of varnish away from taking nursing back to the dark ages (apologies for the rash of cliches!).

    Incidentally, if a new EN is invented, what will then happen to the HCAs? Or. being a conspiracy theorist at heart, would this mean that the number of RN training posts could be reduced? Much cheaper to offer two year courses, largely ward based so lots of extra hands at the coal face, and keep the RNs as managers/specialists – savings all round!

    Good to see you back…

    • Hi Penny. Thanks for commenting. Although I’m expecting it to be a long hard road, I am at least starting to feel a bit better now.
      As I said in the piece, there is a huge and growing tension between the need to train more nurses and the length and academic rigour of a degree course. I think those who make the policy (most of whom have very little understanding of nursing) will be very tempted to get around the problem by diluting/reducing the academic content of degree courses. And I agree, the cost benefits would look attractive to those seeking to save money.
      Proof that politicians don’t understand nursing is evident from these romantic ideas about ENs. The extent to which some of them are stuck in the past, their mental image of a nurse stuck on some comfortable middle-aged woman put their head on her bosom to comfort them when they were at prep school, and missing mum and dad, is really alarming. In the twenty-plus years since EN training was phased out, nursing and health care generally has changed beyond all recognition. Even if ENs were revived, they would not be doing the same job as they were doing in the 1970s.
      Even worse is that so many nurses seem to agree with them…

  2. pennyhaswell permalink

    Apologies for neglecting the mental health side of things previously – had a look on Google, put in Community Psychiatric Nurse and, amongst a whole load of other things the following came up. I appreciate it’s old and that it has been edited, but what sort of impression does it give?
    : › Depression › Depression facts
    6 Jan 2005 – A community psychiatric nurse (CPN) is a fully trained staff or …. not need any qualifications for this job other than a willingness to help others.

  3. I am one of those nurses that agree with them. I spent some of my time this morning discussing with senior nurses “what is the role of the nurse?” Yes, nurses are doing different things these days – that is true – but, much of what they are doing is medical ‘stuff’. Why is it that nurses are not allowed to be proud of nursing? It seems to me that the rhetoric for so long has been that the professional nurse is synonymous with being a graduate. It would seem that you are not a credible practitioner unless you have a degree and I, for one, completely disagree with that idea.

    Why is it that you think that having an EN qualification meant that this was a dead end job with no career progression? I think that would be rather insulting to someone who went into nursing because they wanted to nurse and REMAIN a nurse. Not everyone wants to progress up a career ladder. We actually need people who DO NOT want to progress up a career ladder. We need people who enter nursing because they want to provide care and compassion, who see that being there for someone in their hour of health care need is a privilege. If this isn’t the role of the nurse, whose role is it?

    I understand that providing basic nursing care, remaining a practical, hands-on care nurse, is not a job for life for everyone. Indeed, I loved it whilst I did it but moved out of clinical practice within 7 years of qualifying because I outgrew that aspect of my career. However, I would never denigrate the Ward Sister or Charge Nurse who did that role for over 20 years or more and it would not occur to me that they lacked ambition to climb a career ladder. Provided they were remaining updated, invigorated by their role, leading a high performing team that delivered high quality nursing care, they would be providing an exemplary role model for nurses.

    Whilst I am not enamoured with the ‘6Cs’, I believe that you cannot be a good nurse unless you fundamentally care for people and are compassionate. These are things that I believe are innate; they cannot be legislated for – which is why I think the concept of having to educate people into the 6Cs is fundamentally flawed.

    Nursing IS about caring; about giving touch when needed; about turning people who are bed bound so that their skin remains intact; about giving people time to talk and listening to them; about clearing up their vomit; making sure that they have a diet that is appropriate to their needs; feeding them if they cannot feed themselves; making sure that they are comfortable. If this isn’t the role of the nurse, whose role is it?

    Of course you can teach people who are not nurses to do these tasks. Just as people who are not doctors can be taught to cannulate, listen to chests, strip veins, prescribe drugs, etc, etc. However, if we are not careful, we are going to reduce all health care to nothing more than various tasks that can be carried out by anyone who does the training and passes the course.

    I am deeply concerned about how our profession is being led, the messages that are abounding, the fact that people think that basic nursing care belongs to the ‘bad old days’, and that we have to be an all-graduate profession to be taken seriously. As someone said to me today, they fear for what things will be like when they are 80 and in need of care, because it sure won’t be great if we continue the way we are going.

    It’s about time the profession did some serious reflection and work out where we have been, where we are and what is going to be the likely outcome if we continue in the manner we are. We certainly are not heading for an excellent nursing workforce on today’s evidence. We don’t even provide nurse students with an education that is fit for purpose, unless the objective is to get them out of nursing clinical practice as soon as possible. We need to re-examine what nursing is and go back to basics: what IS the role of the nurse?

  4. HI Barbara! Thanks for commenting as ever.
    Although I had a degree before I entered nursing and have never been an EN myself, I have spent my whole career ‘at the bedside’ and so have many of those who did the post-graduate course with me. It’s not about people not being able to do what they want to do, it IS about not arbitrarily denying people options and opportunities to do what they want to do.
    Enrolled Nurses who did not wish to ‘convert’ to Registered Nurse had no way of progressing their careers. So whilst I agree – of course – that caring is fundamental to nursing, I would question what message that ‘no progression’ status sent out about caring. In my view, it said that caring is something to be done by people who are ‘just filling in time’ or who ‘don’t have the intellectual ability to do anything more challenging’. I cannot see how that helps nurses or nursing. Plus, as a description of most of the ENs I remember, it’s completely inaccurate.
    I think the other thing the nostalgists overlook is that since the early 1990s, when EN training began to be phased out, health care has changed enormously. People who say “Oh, ENs were at the bedside,with the patients, not at the desk doing paperwork” are remembering a time when nursing generally was less burdened by paperwork. Bringing back ENs would not abolish paperwork.
    The only positive of ENs that I can see is that they were regulated and accountable – unlike the assistant practitioners of today who in many cases fulfilling much the same role as ENs (with the opportunity to progress, via honours degree, to RN if they wish) but are not regulated. In this respect, I do think patients are less well-served than they were in the past.

    • Barbara Bradbury, Halland Solutions permalink

      Hi and thank you for your reply, which I appreciate. I, too, travelled the undergraduate path before doing my training and have not been an Enrolled Nurse. However, I don’t agree with your analysis of what being an EN meant. In my experience, the ENs who wanted to progress up a career path did their conversion. I’m not sure why they would have needed to do this if they wanted to remain in their role, so they were not being arbitrarily denied by external forces but were self limiting. I agree that nurses are held in lower status by other health professionals – I remember trying to change the perceptions of junior doctors and medical students when I was a nursing student because they would ask me why I wasn’t reading medicine as I had read physiology as an undergraduate. I constantly made the point that I wanted to be a nurse and not a doctor, that it was a choice made because of the role and that it was nothing to do with academic ability. Indeed, I went to university to read physiology because I was toying with the idea of medicine and had decided that I would progress down that route if it became clear to me that it was my chosen profession. I decided within my first year that it was going to be nursing and not medicine. Nurses have to stand up for themselves and believe that their profession is just as worthy as any other health care professional. Sadly, I don’t believe their status will be held in any higher esteem just because it is a graduate profession.

      Public perception is that it is an easy degree which is why many people go for it. I think there is an element of truth in that – I have two sons, the younger will be going off to university in September, so I am well in the midst of sixth form students.
      I think there is far too much paperwork in the health care system now and it hasn’t improved nursing care from what I can see. However, that’s another issue – and you don’t need a degree to do the paperwork.
      Unless nurses feel a sense of respect and pride in caring, how can they expect others to feel proud and respect them? Sadly, we have sent out a message that caring is not an honourable thing to do – we have relegated this vital aspect of the nurses role to the non-trained HCA, and said that ‘proper’ nursing is about degrees and paperwork. We have done the disservice to our profession in my opinion, and have completely lost our way.

  5. Hi Barbara. Thanks for continuing the conversation.
    I suppose my perception is of a female school-leaver, considered – by a school system which may itself have failed her to some extent – to be ‘less academic’, being pointed in the direction of EN training. It would be interesting to know how many ENs chose that route not because it offered them the job they actually wanted, but because someone made them think that they were not bright enough for RN training. I’m sure you could find plenty of people in the latter category, and it again raises the question of how such a situation elevates the caring skills.
    I’m interested in your view that public perception is that nursing is an easy degree. I wonder if it could have something to do with public perception that caring is easy? But we both know that caring is not easy. And THAT, I think, is the message nurses need to shout from the rooftops.

  6. RGN007 permalink

    Hi , I was first and foremost an EN. I wasn’t channelled into being an EN, I did it be default because I was too immature and vulnerable at age 16 when I became a cadet. I made several false starts at SRN, I didn’t have O or A levels but I did pass the old General Nursing Council test 3 times, even to get in to be a pupil nurse.

    What worries me, is that I never wanted to be a bedside nurse. I seemed to be good at it…I “care”, but I really enjoy administration and loved computers and their potential, but even though I was clever in class, I struggled to cut it in the exams. Because if this, and my dreadful experiences in failing many nursing module by a whisker or a technicality, it doesn’t mean I don’t know what is necessary. All it proves is the exam system does not test me in the way I need to be tested.

    Having a son with Asperger Syndrome has given me tremendous interest in reading about “intelligence” and what we do with it, how we are judged on points and stars. Yet many of these “high achievers” don’t seem to know what to do with their knowledge.

    Basically, I think there is something wrong with the whole education system, not just nursing, but I am sad that nursing appears to be conforming to the rest of the rubble rather than pioneering a different route.

    Half my educational life I feel I have been made to feel stupid. I was top of the class in English yet kept failing the O level GCE so when I wanted to get back in nursing in the late 80’s I was advised to show I had done some relevant study in preparation. Starting with the Open University I embarked on my love of science and technology with a dusting of environmental and public health then research.

    It was great fun going back on the wards as an EN with a BSc Hons but my conversion module was a near miss because I chose a critical analysis on a surgical module of how poor Information Technology was having an impact on the care of surgical patients. My tutor thought my references were wrong…they weren’t, but it was failed by one mark but aggregated to pass for RGN or I would not be here now.

    800 CATS points later and a couple at Master’s level I still struggle to understand the questions but that doesn’t mean I do not know the answers, nor how to apply them. I have a paper published on the Digital Impact of IT on Healthcare with the Royal Society.

    I don’t care what we call “hands on” nurses, ENs, HCA’s, but I think it is a starting point and then choose to go on to do higher level courses.

    The really stupid thing in my mind is that we had ENs who did develop and even some who had MSc in Clincial Nursing, yet even with 15 years or so proving their commitment to learning, when some SRNs and RGNs and some doctors were content to sit on their haunches and do as little as possible, the “Powers that Be” still insist they were Level 2 and had to jump back through basic hoops to obtain the desired Level 1 via conversion…but conversion to what?
    Many had already been doing the job and choosing to do extended learning for many years so why not just add up the points and fill in the gaps in a flexible way?

    I used to be sick and tired of the RCN Publications advertising jobs stating “Level 1 only” when we had then, so many highly educated EN’s who had advanced their knowledge and nursing makes itself so inflexible it blocks out those who have shown so much passion to evolve.

    Today for example, I like clinical coding (Maybe I too have traits of autism) but so often when the patient is with me I have bells ringing in my head with possibilities of how to help that is off track from why the GP has sent them to me. Today I have received an email from a diabetes consultant with whom I queried my disagreement about a GP who keeps de – diagnosing patients with diabetes because they have had bariatric surgery and the bloods are normal again. My insights into coding helps continue caring for the patients by making sure they continue to have eye screening and foot screening, yet the doctor cannot see the risk of complications still exists. I challenge the GPs decisions and take action, yet I am still the same person who used to empty the bins on one ward and was allowed to do what I felt competent to do by a wonderful ward manager on my own ward.

    What I am trying to say is insisting nursing is an all degree profession is not doing nursing any favours. We can still have degrees but why not allow those who choose nursing to develop into what suits what they have to offer and what motivates them. Degrees only is just creating too many chiefs from the outset and no Indians learning their way through the system.

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