Background
Modern nursing
developed in Britain
under the leadership of Florence Nightingale.
The main achievement of Nightingale was to initiate training for women
who aspired to be nurses, but this seminal achievement was preceded by
fundamental changes to the way wounded soldiers were treated in the Crimea and
followed by changes to the delivery of public health in Britain. Nightingale was a consummate politician who
used statistics to support her arguments.
She reached the decision-makers of her day and was held in high regard
by those she cared for and by those through whom she exerted her
influence.
Following Nightingale’s
establishment of a training programme for nurses, Mrs Bedford Fenwick—assisted
by her physician husband—established the first register for nurses whereby
those listed were recognised as having undertaken a prescribed training course
and achieved an agreed level of knowledge and skills. Thereafter, regulatory bodies for nurses were
established in the counties of the United Kingdom (UK) and, notwithstanding
changes to the precise details of what a registered nurse (RN) needed to
achieve and the ways this needed to be demonstrated, the training and
registration of nurses remained largely unchanged until the late 1980s.
From
training to education
The main features of
nurse training until the late 1980s was: schools of nursing located in
hospitals and usually serving a group of hospitals; and two sets of
examinations: one, the ‘hospital exam’ which identified the nurse with the
specific hospital where training had been undertaken, and a ‘state exam’ which
was administered by the nursing regulatory body—the General Nursing Council
(GNC) and its immediate successor in the counties of the UK—and taken by every
nurse being examined at that point on the same day and at the same time. Another feature of nurse training was a
two-tier system of registration (leading to the status of State Registered
Nurses (SRN)) and enrolment (leading to the status of Enrolled Nurse
(EN)). Those undertaking training
courses leading to SRN and EN were, respectively, referred to as ‘student
nurses’ and ‘pupil nurses’. Student
nurses undertook three years training and pupil nurses undertook two years
training. Student nurses trained for
entry to several branches of nursing: general; sick children and mental
(psychiatric and mental subnormality).
All of these qualifications were available post-registration as was
midwifery, for general trained nurses.
Pupil nurse training was generic and could be undertaken in general and
mental hospital settings. Students
(called pupil midwives) could enter midwifery directly and for general trained
nurses and midwives, post-registration training as a health visitor was also
available. In addition, there was a
plethora of post-registration specialist certificates available and further
registration as a nurse teacher.
Until the early 1980s
the training and registration—which included the ability to remove nurses from
the register—rested with the GNC.
However, in the early 1980s the training and regulatory functions were
separated and the United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) was established.
The training functions were devolved to bodies in each of the four
countries of the UK; for example, in England, the English National Board for
Nursing, Midwifery and Health Visiting was established.
The UKCC oversaw the
first major change in the way nurses were prepared in the late 1980s when the
proposals for Project 2000 (P2000) were finalised. The main features of P2000 were a greater emphasis
on the educational preparation of nurses and the establishment of a common
foundation programme (CFP) which constituted the first 18 months of training
and was undertaken by all students, regardless of the branch of nursing on
which they intended to register. With
P2000 came more politically correct labelling of the braches of nursing as:
adult; children; mental health; and learning disability. Midwifery remained a separate direct entry
programme. Student nurses were now more
commonly referred to as ‘nursing students’ and EN training was discontinued;
all nurses who qualified post-P2000 were considered to be ‘first level’ nurses
and conversion courses for ENs wishing to become registered nurses were
offered.
Concomitant with the
changes to the educational preparation of nurses, but not directly coupled to
these changes, was the development—initially in Scotland—of colleges of
nursing. These were formed through a
process of rationalising the myriad schools of nursing that existed in
relatively small geographical areas and, while they often retained premises
within hospitals, this led to the closure of most small hospital-based schools
of nursing. The preparation of nurses thus
moved away from individual hospitals with which student nurses and nurse tutors
used to identify into amalgamated colleges which assumed more of an educational
as opposed to a training identity. The
fate of these colleges of nursing will be picked up below.
Nursing
in universities
In the 1960s, with
funding from the Rockefeller Foundation, an entirely novel venture in nurse preparation
was undertaken with the establishment of a nursing degree programme at The
University of Edinburgh. This was the
first university nursing programme in Europe, although it should be noted that
university education of nurses has a long history in the USA—including the Ivy
League Yale University—and Turkey.
Within a short time university nursing programmes were established in Manchester and Hull and
another early degree programme was offered in London
by Chelsea
College
(now the Florence Nightingale School of Nursing and Midwifery at King’s College
London). Degree programmes produced a
very small percentage of the numbers of nurses entering the register and coexisted
alongside hospital schools of nursing and then colleges of nursing. Over the decades since the 1960s other
universities, and many non-university institutions (colleges and polytechnics)
also offered degree programmes for nurses but the number of graduates remained
in the hundreds as opposed to the tens of thousands of non-graduate nurses in
training.
The 1990s was the next
period of change in nursing education which saw the dismantling of P2000 to
make way for Making a Difference, the main feature of which was to reduce the
CFP to one year, thus decreasing the former emphasis on the educational
component of nurse preparation.
Concomitant with this but, again not coupled to it, colleges of nursing
and any remaining schools of nursing became associated with a local university
or polytechnic. Ultimately, they all
became associated with universities as polytechnics were awarded university
status. In some universities this led to
two-tier systems of nurse preparation within the same university with two
separate streams for graduates and non-graduate nurses. Making a Difference, however, meant that
learning and teaching had to be merged for all nursing students with those on
the degree track undertaking additional assessments. All nursing students were now university
students and all of the teaching staff of the former colleges and schools of
nursing transferred into universities.
During this process, the state examination for nurses was replaced by
examinations set by each of the institutions delivering nursing education. A central state exam did not sit well with
the autonomy of universities; however, there ensued an additional process of
quality assurance—superimposed on the extant internal and external university
quality assurance processes—which was specific to the delivery of nursing and
midwifery programmes accredited by the nursing education bodies across the UK.
In conjunction with the
Making a Difference recommendations, Sir Leonard Peach chaired a UKCC
commission into nursing education entitled Fitness to Practice. Many of the changes suggested here were
reflected in Making a Difference (and vice versa). Fitness to Practice represented the last
major report by the UKCC which was subsequently disbanded, along with the
national boards for nursing, midwifery and health visiting (or equivalent) in
the four countries of the UK. Both the
educational and regulatory functions were subsumed by one body: the Nursing and
Midwifery Council (NMC) which oversaw the professional regulation of nurses
across the UK and also
quality assurance of educational provision in England. The quality assurance of nursing education
was devolved to new bodies in the other three counties of the UK.
The movement of nursing education into universities was completed and in
2010, the most recent change to nursing education was the implementation of all
graduate entry to the nursing register (midwifery had already achieved this)
for nurses entering programmes in 2011.
Public
perceptions of nursing
A generally positive
view of nurses is held by the UK public; one whereby nurses are inevitably
referred to as ‘angels’ and usually considered to be female and in a job to
which they were ‘called’ rather than attracted for personal and professional
reasons. The view of nursing is more of
‘skilled manual labour’ than as a profession, and few outside nursing realise
what the training and educational aspects of the work of a nurse entails. Generally, nurses are not considered to be
particularly intelligent and to be in a job where they simply follow the orders
of the medical profession. The gendered
nature of nursing—in the UK a predominantly female profession with only
approximately 10% of men in nursing—reinforces the view that nursing is for
women. Nursing has not, traditionally,
been considered an appropriate career for men and the view persists that men in
nursing are largely homosexuals. It
should be noted that, traditionally, a higher percentage of men in nursing have
worked in mental health than in general nursing.
Notwithstanding this
generally positive view of nurses, recent events in the UK National Health
Service have led to some negative publicity about nurses and this has been almost
exclusively focused on the preparation of nurses. A very negative view of university educated
nurses is promoted by particular journalists and the prevailing theme is that
university educated nurses are ‘too posh to wash’. This view long preceded the recent Francis
report on care at the Mid-Staffordshire NHS Foundation Trust. The view is supported by a great deal of
inaccurate information; for example, there is a view that university education
for nurses is new, that—prior to 2011—all university educated nurses took
degrees when this is only a recent initiative, that university educated nurses
spent more time in classroom than on the wards when the ratio of education to
practice has never changed at 50:50, and that the subjects that university
educated nurses learned were inappropriate; sociology drawing particular
criticism in this regard. Contrary views
are rarely published and those engaged in university education of nurses are
largely demonised. The recent Willis
report was unable to demonstrate a link between the university education of
nurses and an inability to care; however, it received little publicity. Research from the USA demonstrates the value
of graduate nurses in relation to patient safety; however, this research is
ignored by the UK press and politicians responsible for health and nursing
education.
Failures
in essential aspects of care
Nevertheless, something
is wrong. Alongside anecdotal reports of
excellent nursing care and poor care, the record of truly shocking incidences
of nursing incompetence, neglect and abuse by various bodies which oversee
patient care is undeniable. The blurring
of care roles, the rise in the number of health care assistants who carry out
some tasks previously restricted to nurses—often in uniforms indistinguishable
from registered nurses—undoubtedly increases the ‘collateral damage’ to nursing
from a wide range of possible incidents.
However, somewhere in the process of delivering care in hospitals—the
main area for complaints of poor care—and in the community there are registered
nurses who, if not directly responsible for care, have a vicarious
responsibility.
The range of issues
giving rise to complaint is quite narrow and is focused on essential aspects of
care, inevitably referred to as ‘basic care’ by the media. These aspects of care can be considered
‘essential’ because, without them, the remaining efforts of the
multidisciplinary team are futile.
‘Basic’ implies that these aspects of care can be delivered by anyone
and require minimal training to implement; this is, self-evidently,
untrue. Specifically, when things go
wrong such as: unanswered call bells; patients being left in excrement;
deprived of food and fluids; developing pressure ulcers; and being infantilised
and even verbally and physically abused, there is a problem which cannot be
ignored.
What can be done?
Nursing is held in high
esteem in many other developed countries; for example in Australia nurses
consistently appear in the top five most trusted professions and they top a
similar poll in the USA. In the UK
nursing is not included in polls of professional status; the view remains that
nursing is not a profession. There is
little general appreciation of the specialist and advanced roles that nurses
play across the world, including in the UK where specialist nurses run clinics
for chronic conditions such as rheumatoid arthritis and diabetes, and also
specialise on focused areas such as the removal of foreign objects from
children’s ears. Nurses also conduct
screening endoscopy and in these specialist and advanced roles their work
compares favourably with medically trained practitioners; in some cases they
perform better.
In the USA nursing is a
trusted and prestigious profession and, similar to other developed countries,
nurses work with a great deal of autonomy in many specialist and advanced
roles. Outside of the UK there seems to
be no questioning by the general public or the media of the need for a high
level of education for nurses up to, including and beyond graduate level to
postgraduate: masters and doctoral level.
One crucial feature of the USA system is that educational attainment is
coupled to clinical practice; being prepared at masters or doctoral level
indicates that the nurse is also prepared to practice at a higher level with
the concomitant financial reward. In the
UK, educational attainment has never been linked to practice. For example, nurses qualifying from
university prior to 2013 with either degrees or diplomas entered practice at
the same level with identical job descriptions.
Graduate nurses may have generally been recognised as having a higher
level of preparation but this was not recognised in any other way. In fact, graduate nurses were discriminated
against by the National Health Service by being awarded only a 50% bursary for
their studies compared with diploma nurses being awarded a full bursary. Notwithstanding that, their place has been
confirmed in universities—and at degree level—but nursing education remains
funded, albeit indirectly, via the NHS and this sets them aside to some extent
from other UK students who are funded by the Higher Education Funding
Council. Nursing students are probably
insensible to this, but it does mean than nursing education remains to a large
extent under the control of the NHS and the expressed intention, wherever
nursing education takes place, is to train nurses to work in the local NHS. Thereby, UK nurses tend not to benefit fully
from being in university; their vision tends to be restricted to local health
care and, when nursing students do not end up working in their local NHS
Trusts, this is viewed negatively.
Therefore, the problem
remains of investigating UK nursing education to see what, if anything is wrong
with the preparation of nurses. How, for
example, do we close the gap between a military nurse—at risk of losing her
life—shielding a wounded soldier in a convoy in Afghanistan and a nurse who
refuses to fetch a drink of water for a dying older person? How do we raise the profile of nursing, for
the right reasons, in the eyes of the UK public and press? How do we use the available evidence that
there is a relationship between performance and educational level of nurses to
convince decision-makers to back an educational agenda for nurses?
Roger Watson
20 December 2013
