On the Andrew Marr show today Ann Clwyd MP was speaking angrily about the poor care her husband received while at the University Hospital of Wales. She argued that nurses no longer display compassion, and one of the reasons for this was because, “since they made nursing a degree course the wrong kind of people are entering the profession… we do not need a load of snooty-nosed pen pushers”.
A couple of days ago Jo Brand gave a response in the Guardian to Mrs Clwyd’s recent statements on nursing. Her view was that nurses are not any less compassionate than they used to be, but that poor management, spending cuts and privatisation were eating away at standards of care. She too raised the question of nursing degrees, though she describes it as “a complex issue that is difficult to read.” She expressed concern that it might have “closed the door to a wealth of potentially impressive nursing staff whose academic skills were not up to degree level.”
I fully appreciate Mrs Clwyd’s anger and upset at her husband’s (lack of) care. Who wouldn’t be angry? But I don’t think nursing degrees are part of the problem, and I’d like to give some reasons why I think that. I hope this goes without saying, but in doing so I am not attempting in any way to excuse or minimise the failings with regard to her husband. Patients are entitled to dignity and compassion at all times, and if he did not receive it that is clearly unacceptable.
Nursing has been an all-degree profession in Scotland and Wales for some years now, and is in the process of switching over in England. I’ll declare an interest here in that I’m a degree-educated nurse who graduated with first class honours from a well-regarded Russell Group university. It was a tough, challenging course, which stretched me far harder – particularly emotionally and physically – than my previous degree in the humanities.
The first point to make is that the difference between a nursing degree and a diploma really isn’t very much. The length of time is exactly the same (three years) and crucially, the clinical placements are exactly the same. Whether a student is doing a degree or a diploma, they spend half their time in university and the other half out on placement – in hospital wards, outpatient departments, community teams. At the end of the third year, they spend the last three months of the course in a clinical area, taking on all the responsibilities of a staff nurse under the supervision of the qualified staff. At my university, the difference between a degree or a diploma was little more than whether you did a dissertation or an extended essay in the third year.
So, if the clinical placements haven’t changed, what about the suggestion that bringing in degrees has attracted a horde of snooty people who are, to use the media expression, “too clever to care”? Personally, I don’t see that it has. When I was a newly-qualified staff nurse on a ward, I certainly didn’t think that my fancy education meant I was too intelligent to wipe a bum. On the contrary, I felt very strongly that I needed to gain the respect of the nursing assistants I was now leading, and that meant demonstrating that such tasks weren’t beneath me. I really don’t see why having more intelligence would make you less compassionate, or that being clever makes you a bad nurse. On the contrary, when I think of the most outstanding nurses I’ve ever worked with, they’ve all been intelligent people. As for the bad ones, they’ve usually been…well, a bit dense. Nursing requires you to juggle a caseload, calculate medication doses, keep accurate records, liaise with patients, carers and fellow professionals, and think on your feet in rapidly-changing situations. Funnily enough, it helps to have something between your ears.
Then there’s the argument that degree courses are deterring people who would otherwise make good nurses. Again, I’m not convinced. I’m willing to stand corrected on this, but I haven’t heard anyone say, “I was planning to apply for nursing, but now they’re abolishing the diplomas, I’m not going to.” In an era of mass education, university degrees simply aren’t the elite qualifications they used to be perceived as. These days it’s practically a rite of passage school leavers to head off to university, and most people with a reasonable amount of intelligence and self-organisation can pass a degree. Some of the students on my course struggled with the essays, particularly mature students who had been out of education for some years. But crucially, those who kept at it did pass. They might not have got stellar grades, and they might have had to re-submit the odd essay, but they did get through. Once they’d done this, a nursing graduate who scraped a third is just as qualified as one who sailed through with a first. As for those few who flunked completely despite opportunities to resubmit work, they really didn’t come across any great loss to the profession.
Finally, it’s important to remember that many things can affect patient care and dignity besides nurse education. The ratio of nurses to patients. The ratio of qualified nurses to unqualified nursing assistants. Levels of support – is there a ward receptionist to deal with phone calls and queries so the nurses can get on with caring for patients? Equipment issues – for example, is the ward getting enough fresh linen? The calibre and personalities of the senior nurses. Even cultural factors can play a role. Those who gaze wistfully back to regimented wards under the dictatorship of Matron might wish to recall that back then Britain was more, well, regimented. When the NHS was founded it was the era of national service, with the Second World War still fresh in everyone’s memory. The values of nursing at the time were essentially military values. We don’t have that culture in Britain any more.
That said, there is the question of whether enough is being done to weed out bad student nurses and stop them qualifying. It makes a good headline to say it’s because universities only want them to write essays. But as is so often the case with a good headline, the reality is more complicated than that. For people who are interested in this topic, a good read is Kathleen Duffy’s seminal 2003 study on “failing to fail” student nurses. Unlike in the tabloid headlines, her focus wasn’t so much on the universities, but on the mentors; the qualified nurses who teach and supervise students while they’re out on placement.
I’m a mentor myself, and I regard it as one of the most rewarding parts of my job. Every few months I have a student nurse with me for six weeks, so they can develop their knowledge and clinical skills. It’s up to me to support them and also to assess both their skills and their professional attitudes. I’ll not just be looking at their ability to perform a task, but whether they interact well with patients and families, whether they respect confidentiality, actively seek out learning experiences, and so on.
For the most part, the students I’ve had come to me have been excellent. Keen, bright, eager to learn. But there remains the question of what to do with a bad student. Hence why Duffy’s paper was required reading when I did my mentorship training. She identified various reasons why a student might not be performing but still pass a placement, which she placed in four categories.
- Leaving it too late – not identifying and addressing problems until the last week of the placement, perhaps not having a mid-placement meeting as you’re supposed to.
- Personal consequences – an awareness by the mentor that this could result in a student’s career ending before it’s begun, with all the ways that might affect them and their families.
- Facing personal challenges – a lot of nurses simply don’t like failing students because they feel it’s not a “nice” thing to do, particularly in a profession that’s supposed to put a premium on being nice.
- Experience and confidence – mentors not feeling sure of their judgement in these matters, or perhaps being worried about getting a hostile response from the student.
Obviously none of these are valid reasons for passing an under-performing student nurse. Ultimately it’s our responsibility as mentors to flag up problems promptly and address them, for the benefit of the public. The take-home message from Duffy’s research is that if the wrong people are being allowed to qualify as nurses and join our ranks, then it isn’t the university’s fault. It’s our fault.