The first ever paper to appear in the International Journal of Nursing Studies, when it was first published in 1963, pointed to the benefits of a university education for nurses and health visitors (O’Connell, 1963). It took another 50 years, until 2013, for an undergraduate (bachelor’s) degree to become the entry qualification for all registered nurses in the UK. Towards the end of that same year, in a major speech, a senior member of the British Government, the Business Secretary, the Right Honourable Dr Vince Cable MP, said that a university degree is ‘superfluous’ to many jobs, and cited nursing as a prime example. So it seems that, as soon as bachelor’s degree qualification has become the norm in the UK, it has come under attack.
Dr Cable said that a sharp rise in the number of jobs that require a degree as a minimum entry requirement has led to ‘qualification inflation’. He argued that the rise in the number of graduate-entry jobs is largely responsible for a substantial increase in the number of school leavers going to university, which in the UK now stands at a record 49% in 2011–12, up from 46% the year before. And this surge in university education is the cause of a large number of graduate university leavers being left unemployed or in low-skilled jobs with qualifications which, Dr Cable suggests, do not meet the needs of a modern economy. In addition to nursing, Dr Cable cites accountancy and policing (which in the UK does not require a degree but fast tracks graduates into senior ranks) as other examples of qualification inflation. Dr Cable said: ‘The idea that in order to be a police officer or a nurse you have to have a degree, I mean, that’s just qualification inflation … There may be some qualitative improvement associated with it, but arguably not’ (Paton, 2013).
Dr Cable’s comments are a timely reminder that, in the UK and in some other countries too, nurse education cannot sit on its laurels. It is too easy to believe that nursing and midwifery education is firmly established in universities, although in practical terms it would certainly be difficult for any government to ‘de-graduate’ nursing. But university preparation for professional nurses and midwives is under continual attack from the British media and by politicians and the case for the graduate nurse needs to be made time and time again.
My mother was a nurse. In the 2nd World War, she was an officer in the Queen Alexander’s Nursing Service and served in India and in Scotland. My mother was an intelligent woman but, along with most of her generation (and women in particular), she did not have the benefit of a university education; back then, around 3% of the British population went on from school to university. Arguably, she did not require a graduate education to become what was regarded at that time as a good nurse. I’m sure she was kind and compassionate and technical aspects of care, such as they were (such as taking blood pressure readings and urinalysis) was usually the work of doctors. Moreover, the care that my mother gave patients would have been based on tradition, habit and the medical consultant’s preferences.
Nursing may have a common core, a common philosophy that my mother and nurses today would recognise. Care and compassion continue to be prerequisites. But nursing has changed since my mother entered the profession.
The Institute of Medicine (2003) has identified five core competencies that nurses and indeed all health professionals, regardless of discipline, should possess if they are to meet the healthcare needs of the 21st century. They need to be able to:
-provide patient centred care (including respect for preferences and expressed needs, coordinate continuous care, inform and communicate with patients clearly, promote wellness and healthy lifestyles including a focus on population health);
-work in inter-disciplinary teams (collaborate and communicate to ensure that care is continuous and reliable);
-apply quality improvements (including identifying errors and hazards, understand and measure quality of care, design and test interventions to improve care quality);
-utilise informatics (manage knowledge and support decision making using information technology); and
-employ evidence-based practice (integrate best research with clinical expertise and patient preferences).
It is difficult to envisage how nurses could develop these core competencies without the benefit of undergraduate university education. The skills of patient centred care must be honed in clinical practice. Among the criticisms laid at the door of graduate nurses in the UK, it is too frequently forgotten that UK nurses spend 50% of their university degree based in clinical practice. But I doubt that nurses could acquire the competencies required for population focused health, health protection and promotion and illness prevention without university based study. And university is also the natural place to learn about issues such as root cause analysis and error reduction, process measurement of patient data and service redesign, which are essential to quality improvement processes. A recent special issue of the IJNS highlights, that these processes have emerged as an important and distinctive field of study (Sales, 2013, Van Achterberg, 2013). And whilst children seem to naturally have the capability to interact with computers as part of their education, these skills are very different to those needed to apply informatics to patient care.
And then there is now the ubiquitous philosophy of evidenced based practice (McCrae, 2012). Unlike my mother, whose practice followed the doctor’s expert opinion, today’s nurses need the capabilities to continually update their practice and ensure that it is evidence based or at least to know if it isn’t, or that there’s not enough evidence to know one way or another. They need to be able to: ask questions of their practice which are answerable with reference to evidence, search for the evidence to address their questions, critically appraise the evidence (sort out the “wheat from the chaff”, distinguish valid evidence from invalid evidence), synthesise the evidence to identify practice implications, and then apply that evidence (probably the most difficult step) to the care of patients, their families and increasingly populations in a public health role. These capabilities are amongst those that demonstrate ‘graduateness’.
A graduate education provides the capabilities required for lifelong learning and adaptation, which is essential when one considers the development of nursing roles. Old arguments about the legitimacy of role extension and role expansion have been superseded by the requirement to deliver benefits for patients. Evidence of the increasing complexity of nursing is evident from papers published in recent volumes of the IJNS. For example, Thompson and colleagues (Thompson et al., 2013) point to the contribution of nurses’ judgements and decisions to efficient resource allocation, health gain, patient benefit and prevention of harm. Kilpatrick et al.’s (2013) study of acute care nurse practitioners within healthcare teams highlights the impact of the transfer of prescriptive authority and decision making autonomy on nurse practitioners’ role development; and Kilpatrick et al.’s (2013) investigation of the work and impact of clinical nurse specialist roles in Canada showed that these nurses are engaged in a wide range of activities and are based in settings which go well beyond traditional tertiary care settings. In another recent study, Wilson et al.’s (2012) investigation of the contribution of nurses to chronic disease management found that patients were more satisfied if nurses adopted the role previously occupied by doctors and saw the nurse as diagnostician, prescriber and medical manager of their condition. A final example is Coffey and Hannigan’s (2013) consideration of the challenges faced by mental health nurses who take on a statutory role as an approved mental health professional in the UK within a new framework for the detention, assessment and treatment of people with mental disorder. The complexity and dynamic nature of nursing roles makes the traditional apprenticeship model of nurse education outdated. The good news is that a study of graduate nurses in Sweden found that nurses’ evidence based practice remained stable and generally high five years following graduation (Rudman et al., 2012), although there were also individual differences which also remained stable over time.
Add to this the evidence from studies demonstrating lower mortality among surgical patients in hospitals which employ a higher proportion of graduate nurses (Kutney-Lee et al., 2013), and the clear conclusion is that nurses need more higher education, rather than less. Indeed, it has been argued in the New England Journal of Medicine (Iglehart, 2013) that advanced practice registered nurses offer a solution to the impact of the US Affordable Care Act which threatens to overwhelm the capacity of the primary healthcare system as an additional 15 million uninsured persons receive health cover in 2014, rising to 35 million by 2016. But only if nurses are enabled to achieve higher levels of education through an improved education system which allows seamless academic progression; practice to the full extent of their education through the elimination of regulatory barriers and scope of practice restrictions imposed by highly variable state laws; and become full partners with physicians and other health professionals in redesigning the primary health care system.
So, returning to the UK, Dr Cable may be correct that there is qualification inflation, and it may also be true that the modern economy would be better served by allowing entry to some professions with lower level qualifications, such as A-levels (the examination taken by British schoolchildren at aged 18) and apprenticeships. I’m not qualified to comment on policing or accountancy, but what I am certain about is that nursing is not one of these professions. Dr Cable’s claim that a university education is ‘superfluous’ to nursing practice, shows that he is working with an outdated conception of nursing. However, more worrying in my view is that Dr Cable’s views are shared by many other British politicians and substantial numbers of the British public. I am not aware of an opinion poll, but if asked whether nurses need a university education I would guess that the great majority of the British would say ‘no’.
Editorials like this, which extol the vision of an educated nurse, are unlikely to have much influence. For the most part, I am preaching to the converted – but even if this editorial goes beyond the IJNS readership, it is unlikely to have impact on public or politicians’ perceptions of nursing. When a view such as this is advanced by a professor of nursing in a UK university, it invites the comment made famous by Mandy Rice-Davies, who was involved in the British Profumo Affair in 1963, the year this journal was first published. Giving evidence in the trial of Stephen Ward when the prosecuting counsel pointed out that Lord Astor denied an affair or having even met her, she replied, “He would, wouldn’t he?” And therein lies nursing’s problem. Our challenge is to win the hearts and minds of the public. And the first step, in my view, is for all nurses, not just those with an obvious vested interest in graduate nursing, to respond robustly to critics of nurse education by giving clear reasons why nursing must be a graduate profession. Modern day nursing requires people who can think for themselves and take the initiative in care, rather than simply follow doctors’ orders as my mother would have been expected to do. In the increasingly complex world of modern health care, nurses are expected to work with other highly educated professionals as equal colleagues and to lead significant aspects of patient care; that demands a university based graduate education.