Monday, 6 November 2017

Me or them? First-person versus third-person writing

I am writing this blog; it is not ´being written´- that would be vague and imprecise. Why, therefore, is a research project ´done´, apparently as if by magic and, moreover, why has it been done by ´the researcher´- presumably the person who has duly ´done´ the research?
I deliver workshops and seminars on writing for publication across the globe. While I often have comments on some of my more controversial views on academic writing, I never fail to have an argument with a participant or an audience member on the issue of first person writing. Essentially, I propose—with evidence—that it is acceptable; I am repeatedly told that it is not. Why? Because that is the nonsense we teach people at school and then perpetuate at university. ´First person writing is not scholarly´—thus, we infect people with this ridiculous notion (akin to the nonsense about not usingsub-headings in essays) in the face of copious evidence and the demonstrable fact that the academic publishing industry has long since ´moved on´.
So, where is the evidence? Well, only in the most famous and revolutionary scientific article ever written, by James Watson and Francis Crick, in the world´s leading scientific journal Nature as long ago as 1953 (before the author—sorry, ´I´—was born). The opening line is a classic both in scientific modesty and politeness—despite the fact that these two were far from modest or polite—and first person writing as in:

´We wish tosuggest a structure for the salt of deoxyribose nucleic acid (D.N.A.).´

The Watson and Crick (1953) example is not isolated, either in concept or in time, as demonstrated by the opening two sentences from a 2017 article based on a recent multi-country study from The Lancet as follows:

´We did a prospective cohort study.... We documented their diet using....´

Apart from the obvious directness and active nature of first person writing as opposed to the vague and imprecise nature of passive´it was done by the researcher´—writing, first person writing often uses fewer words and fewer words is always better and preferred by editors. This is due to the need to save space and to increase precision. But first person writing also makes the narrative more engaging, even in relatively dry subjects, and demonstrates that the writer really ´owns´ the work. Passive writing detaches the person from the ideas, which some see as a virtue, but which is entirely pointless.

The academic publishing industry is in no doubt about first versus third person writing. I ´wish to suggest´ that we abandon it in academia as an out-dated and unnecessary concept.

You can listen to this as a podcast

(c) Yould Publications Ltd

Thursday, 31 December 2015

Subverting the headerless (and sub-headerless) chickens

Who tells nursing students not to use headings and sub-headings in their assignments?  Worse, who tells nursing students that they will be penalised if they use them?

I am being quite specific here, by the way, as this ridiculous phenomenon appears to be unique to nursing academics.  Frankly, I'm sick of it.  I've had arguments with colleagues about it, I still supervise undergraduate student assignments and when I suggest to the students that using headings and sub-headings would improve their work I am almost inevitably told, in cowering terms, that some colleague - usually less experienced than I - has warned them sternly against it.  I have asked for the proof of this, in writing, and it has NEVER been produced; instead, if I confront colleagues about it I am told that everyone knows that good writing does not need headings and sub-headings (ie EVERYONE knew that - why didn't you?) and that they interrupt the flow of the writing.  All complete nonsense and, in fact, the opposite is true.

The least of my worries would be be specifically offending my 'headerless' immediate colleagues; nevertheless, to assure them I am not targetting them, I have encountered this in more than one of the universities where I have worked.  Two of my daughters are currently studying nursing at post-graduate and post-registration levels at other universities and, whenever they show me their work and I suggest headings and sub-headings, the refrain is the same: 'we have been told not to'.

My own background is in biological sciences (The University of Edinburgh) and I hold a PhD in biochemistry (University of Sheffield) and I have edited academic nursing journals for over 20 years.  Currently, I am Editor-in-Chief of the most cited academic journal in nursing.  My publication record of books, chapters, academic articles, professional articles and other contributions such as editorials and comments exceeds 500.  In none of these endeavours has using headings and sub-headings ever presented a problem.

I was one of the earliest Members of the Institute for Learning and Teaching and a member of their accreditation panel.  Neverthless, when I have questioned colleagues about this quirky aspect of nursing education I have been treated with considerable disrespect - not being a Registered Nurse Teacher - which is where this vacuous concept seems to stem from.  The uniqueness to nursing has been further emphasised to me by colleagues from student support services in this and my previous university who have questioned me - in somewhat desperate and disparaging tones - about why they cannot seem to convince nursing students to use headings and sub-headings in their work.  I know there is a tradition in essay writing of not using them but when I have questioned colleagues in English departments if they would penalise students for using headings and sub-headings, I have - invariably - had the response 'no!' in a 'why on earth would we?' tone.  Other than some form of received 'wisdom', there is no substantial basis for discouraging or penalising the use of headings and sub-headings.  Like a virus, this idea has infected nursing education and spread.

The case for headings and sub-headings
The case hardly needs to be made; instead, try naming any style of writing that does not have headings and sub-headings and you will see how risible the 'headerless chicken' brigade really are.  Books of all kinds - antiquarian and modern - academic articles, journal articles, newspapers and even 'round robin' letters use headings and sub-headings.  Imagine a newspaper which started at the top left hand side of the front page and proceeded to the bottom left of the back page...without a break.  'Ah but', the 'experts' in nursing education say, newspapers and academic articles are a different type of writing from essay or assignment writing.  How so?  There is only good writing and poor writing - whatever the platform.  Telling a joke and making a scientific argument require precisely the same style: as few words as possible and packed with meaning.  'Ah but', reiterate the experts, the headings and sub-headings help people to find information in newspapers and academic articles which point entirely.  Why should the reader not be facilitated in finding information in an essay?  'Ah but', - experts opine - headings and sub-headings break up the flow of the writing and my view is: 'thank goodness'.  When we are reading, we all need breaks and how much better is it that the writer can indicate where the breaks should take place?  Otherwise, if the readers make their own decisions, they the flow of the writing.

How do we help students?
With difficulty I think as it is our colleagues who need help.  Nevertheless, when faced with students who seems clueless about how to organise their writing (usually because they have not encountered headings and sub-headings before) I exercise a neat piece of subversion: I  suggest a few headings and sub-headings and tell them to write under those.  Then, when they are happy that their assignment is complete, remove the headings and sub-headings and submit.

Monday, 18 May 2015

The case against bursaries and fee payments for nursing students

Roger Watson, Professor of Nursing, University of Hull
Editor-in-Chief, Journal of Advanced Nursing

In the UK nursing students do not pay fees to attend university and they are provided with means tested bursaries for personal support, which does not have to be paid back, and this is financed by the National Health Service.  Two questions arise: 1) is this a fair system?; 2) is this a necessary system?  I contend that the answer to both questions is 'no'.

The system is not fair because it does not apply to other university students who have to pay fees and take out a loan for personal support.  Arguments about the level of fees and the demise of education authority grants for the personal support of students aside, why should nursing students in the UK be supported in this way?  In the USA and Australia, for example, nursing students do not receive such support; they pay fees and support themselves through university education, like any other student.  I suppose a supplementary question is: why do we support nursing students in the UK in this way?

The answer is: I don't really know.  One aspect of the funding of nursing education in the UK, which is now wholly incorporated into universities and now leads to an all graduate entry profession, is that it is funded by the NHS.  This sets it aside from most other university subjects which are funded, for UK students - in addition to the fees they pay - by the Higher Education Funding Councils or equivalent bodies across the four countries of the UK.  I am a strong advocate for breaking this link between the NHS and nursing education, whereby nursing education is commissioned by local bodies which administer the NHS funding, and for nursing education to be funded like other subjects.  One reason for this is that the process does not work: witness the shortage of nurses, the attrition of nursing students and the high dependence of the NHS on overseas nurses.  However, it does not work at the local level where universities essentially 'jump to the tune' of the commissioning bodies who demand increases in nursing education places without, for example, taking any responsibility for providing clinical learning places for those students in the hospitals and the community.

Nursing students 'work' long hours

Another reason given is that nursing students 'work' in the NHS and have less holiday time than other students.  But nursing students do not work in the NHS, they are supernumerary, a principle that was established with the advent of Project 2000 in the late 1980s and which has not changed.  Nursing students may, indeed, work hard while they are in the clinical areas and undertake all manner of unsocial working hours; however, they are not part of the established workforce of the NHS.  In practice, supernumerary status is often breached, but that is beside the point and does not alter the principle.  It is not a justification for bursaries.

Clearly, it is a considerable bonus for nursing students when they enter nursing education not to have to pay fees and to have some guaranteed income, but the logic of this escapes me.  It presents a patronising image of nursing students as being a special case almost unable to negotiate the maze of higher education and students loans, like other students have to do, and that they are not quite like other university students.

The system of funding applies to some aspects of postgraduate education for nurses.  For example, Advanced Nurse Practitioner programmes are funded by the NHS but this takes place locally to address local needs.  At considerable expense, a nurse can be trained as an Advanced Nurse Practitioner over two years, possibly up to masters degree level, qualify and leave that area of the NHS.  While the good of the UK may have been served if that nurse remains in the UK, the money has been wasted by the area of the NHS which funded the training.  Surely another argument, whether money rests with the NHS or not for postgraduate education, for a more centralised planning system based on national and not local need.

Nursing students just do it for the money

A major worry for some academic colleagues and students who have expressed this to me is that some nursing students enter nursing education simply because a bursary is available.  I have heard this often enough for it not to be ignored.  Nevertheless, I realise that 'the plural of anecdote is not data' and that some work is needed to establish how widespread this is.  However, the high attrition of nursing students (anecdotally reported to be 50% in some universities) and the high attrition of nurses in their first year of clinical practice could point to some lack of commitment among some nursing students, actually, to becoming a nurse.

Whatever the reason for the high attrition - and the reasons are hard to identify - the bursary system is not working to maintain students in education and, subsequently, nurses in practice.  I speculate that a nursing education system where nursing students paid for their education and supported themselves like other students may raise the level of commitment to qualifying and remaining in the profession.  I speculate because I realise that attrition rates are also high in the USA and Australia and that this may have a minimal effect on attrition.

Recruitment to nursing programmes and preventing 'good people' from entering the profession

There is some concern that recruitment would suffer without an inducement to enter nursing education.  This is unlikely given that the numbers of applicants vastly exceeds the number of places available on nursing programmes.  Currently, we have to turn away many suitably qualified applicants and make decisions based on spurious grounds such as personal statements and interviews.  The process is expensive as it requires many hours of university and NHS colleagues' time.  If bursaries are the inducement to enter nursing education then ending them may make the numbers of applicants more manageable, and we will definitely see who is committed to nursing over and above the favourable financial inducements.

Keeping 'good people' who may not otherwise apply for nursing education out of the system does not  apply to any other university subject or profession, so why should nursing be hostage to the 'tyranny of niceness'?  Concomitantly, it is worth noting that, until entry to the nursing profession became by degree only in the UK that nurses undertaking degrees were discriminated against; they were not eligible for the non means tested bursary.  This was a clear indication from successive UK governments of all shades about what they preferred and what they and the NHS thought of graduate nurses.  It is interesting to note that places on degree nursing programmes remained universally oversubscribed; the message is that some people do want to do nursing, they do care about having a degree and they are willing to sacrifice to obtain it.

Friday, 13 March 2015

Project Making a Shape of Francis

Roger Watson

Yesterday - 12 March 2015 - Willis II, Raising the bar The Shape of Caring: a review of the future education and training of Registered Nurses and care assistants was published. My impression is that this offers a new way back to the past of nursing education; there are some good proposal therein but, otherwise, this is a crossbreed between the visionary Project 2000 (the common foundation programme is back), the disastrous Making a Difference (widening access to nurse education and contiguity between care assistants and registered nurses) and, of course, The Francis Report (standardised training for care assistants).

First the good points.  While there is little that could be described as visionary in Willis II, the proposal under Theme 6 (Assuring predictable and sustainable access to ongoing learning and development for registered nurses) for a possible future model of postgraduate pathways involving memberships and fellowships is excellent.  Some will say it apes the medial model of education and career pathway, but so what?  They're successful...nursing is not!  The proposal is sketchy and one vital ingredient is missing -  funding; I would not expect Willis II to make detailed funding proposals but the incredible disparity between, for example, the budget for medical postgraduate training and nursing postgraduate training is, apparently, huge.  Willis II does call for greater transparency about this gap; that would be a start.

Care assistants form a main focus of Willis II.  The proposals under Theme 2 (Valuing care assistants) are largely about ensuring proper education and training for care assistants, defined role descriptions and transferability of competences through a national database.  All good, very much an echo of the best of Francis - which the government ignored - but stops short of a register.

Sadly, there it ends.  Making a Difference raises its ugly head again in terms of Theme 3 (Widening assess for care assistants who wish to enter nursing).  Like Making a Difference, Willis II tries to stretch nursing to the limits: fellowships at one end; widened access at the other.  I would take such proposals seriously if anyone were calling for widening access (other than for the working classes, ethnic minorities and women which have thankfully been addressed with some success) into medicine.  However, this is about widening access to people who, frankly, did not make the grade first time round - to which a fair amount of altruism can be ascribed - but then crediting them with part of the care assistant training towards their nursing education.  Care assisting is not nursing and surely it is time to put some clear blue water between care assistants and nurses.  Nurses may be assuming medical and surgical tasks at the 'upper end of the care spectrum' (in inverted commas as I also have doubts about how 'caring' these tasks are) but there is an ocean of turbulent water before you even reach the clear blue stuff between nursing and medicine - de facto and de jure.  I am perfectly happy for care assistants to enter nursing education and even medical education but the difference between one and the other should be clear, they should meet the appropriate educational entry standards and undertake the whole programme.

Naturally, there is more to Willis II about the necessity for research (good), appropriate funding models (the present one is holed with cabins being built as we sink) and the usual stuff about patient and public involvement.  Buried in all of that Willis II makes the interesting point that the number of nursing professors is 0.1% of the nursing workforce.  The implication is that there should be more of us but I can't wait to see which 'eagle-eyed' broadsheet journalist spots that one and gives Willis II a good pasting.  We are seen as being part of the problem and not the solution and no politician from either end of the political spectrum is going to support that vote-loser.

A final word about the structure and information sources for Willis II.  The report is 'splattered' (I just cannot find a better word) with case studies (Bob is 70 and has diabetes...), photographs, voice bubbles and inforgams.  Not all bad, but the tone seems to be that which would be used to address a group of five year olds which begs the question: 'just for whom was this written?'  The information sources are wide and largely low level: eg Twitter and discussions with nursing students.  I'm an avid tweeter - especially during my reading of Willis II - but just who were the thousands of tweeters who contributed views to Willis II?  And, are nursing students the best source of opinion about nursing?  I was a student full of opinion about nursing and the NHS and most of those views changed under the experience of being a staff nurse and a charge nurse mainly because I only thought I knew what I was talking about (plus ca change?).  By all means we need to know what nursing students think about their programme, its delivery and content and quality but they are not yet nurses and they are not responsible for nursing education.

The 6 C's made a cameo appearance in Willis II to which I would add a 7th: curate's egg.

Saturday, 3 January 2015

Correspondence on letters page of UK Daily Telegraph 16-22 December 2014

This is a recent trail of correspondence from the letters page of the UK broadsheet right of centre newspaper The Daily Telegraph.  There were several letters on 18 December 2014 alongside Professor Dame Jessica Corner's which were negative and trivial, which I do not include.  The Daily Telegraph is no friend of university educated nurses and it was a major achievement for Professor Corner to have her excellent letter published where so many of us have failed to get into these pages with a positive view of university educated nurses.  Note how the final letter in the trail is negative, coming long after the event but by an FRCS - so he must know what he is talking about:

16 December 2014

SIR – Has it occurred to the UK nursing authorities that the current university-based training system may be a significant disincentive for those interested in a nursing career?
It certainly was for our daughter, an ideal candidate, who was discouraged by a further three years in academic study after successful completion of her A-levels.

John Kellie
Pyrford, Surrey

17 December 2014

SIR – John Kellie is right to question the usefulness of a three-year stint at university for those contemplating a nursing career (Letters, December 16).
The excellent ward sisters I encountered during the 13 years I chaired an NHS Trust had learnt their profession effectively as apprentices straight from school.
Young people not pursuing higher education should go to their local hospital to try nursing for three months. If they are still interested after looking after patients’ most basic and personal needs, they most likely will make the grade and stick with the job instead of aspiring to pseudo-management positions that have almost nothing to do with hands-on care.
Introducing degrees has changed the nursing profession.

Peter Hayes 
Siddington, Cheshire

18 December 2014
Jessica Corner

SIR – It is a myth that degree-level education for nurses is bad for patient care (Letters, December 17). A study of nurses in 11 European countries (including England) by RN4CAST, the research group, has shown that hospital mortality is approximately seven per cent lower for every 10 per cent increase in the proportion of nurses with degrees.
Research in America also found that a 10 per cent increase in the number of nurses with a bachelor’s degree was associated with a five per cent reduction in the likelihood of patients dying within 30 days of admission.
Given this data, it is unsurprising that every major British review of nursing over the past 20 years has supported degree-level education as the right preparation for the challenging and complex roles that nurses undertake.
We should be proud of our graduate nurses, help them to apply their skills to lead innovation and improvement in patient care, encourage them to engage in research and support them in challenging poor practice.
This should not distract us from a broken workforce planning system that has delivered a predictable crisis in the number of new nurses following 20 per cent cuts in the number of places between 2010/11 and 2012/13.
Related Articles

Prof Dame Jessica Corner 
Chairman, Council of Deans of Health
London WC1

22 December 2014

SIR – Prof Dame Jessica Corner quotes statistics that purport to demonstrate that an increase in the number of nurses with degrees has resulted in a decline in hospital patient mortality. Two events occurring together do not necessarily have a cause-and-effect relationship.
Britain is experiencing a serious nursing crisis with a major shortfall in the number of British-trained nurses available and an inevitable dependency upon the recruitment of nurses from abroad. Insisting on degree-level qualifications will deny many dedicated young people the opportunity to serve in this wonderful profession.
Completing more traditional training and gaining experience on a hospital ward establishes that the individual is truly committed to becoming a nurse.

Malcolm H Wheeler FRCS

Friday, 20 December 2013

Proposal for a Lancet commission on UK nursing

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

Saturday, 16 March 2013

Correspondence with Stephen O'Brien MP

On Wednesday 13 March during Prime Minister's Question time in the British House of Commons I picked up on Twitter from Michael White that Stephen O'Brien MP had called for nurses to return to the bedside and get out of the classroom (The Prime Minister resisted); here is the text of an email I wrote to the MP:

Stephen O'Brien
Dear Mr O'Brien

I see from PMQ you have joined the 'back to the bedside' brigade. I trained under the pre-university system and we spent 50% of our time in classroom. I now teach in the University system where students still spend 50% of their time in the classroom.  I recall excellent ward sisters and charge nurses (I used to be one of the latter) who had authority and experience and a genuine interest in students. The NHS has changed beyond recognition and the ward sister/charge nurse is no longer in charge in the same way - this has been studied and reported and the role of the ward sister/charge nurse is widely acknowledged as key to the training of students and the setting of standards in the clinical areas.

Therefore, we've always been trained at the bedside; it's the matter of who trains us that is the issue, the ward sister/charge nurse is no longer effective and the hallowed job of clinical teacher no longer exists, the NHS decided to do away with them, not the universities.  There can be no return to the bedside as we've never been away; if you are suggesting more time at the beside, where are the role models and what will the students learn anyway? I have two daughters working as nurses in the NHS who keep me informed.

Finally, we must remove the rose tinted spectacles through which we view the past in nursing. I recall incidents and practices as an auxiliary and a student that were truly appalling and accepted as the norm.  Things are bad in some places; Mid-Staffs is not the whole NHS. There is frank prejudice against Univeristy educated nurses but it is really prejudice against a large section of the working population and a largely female one.  The view that, perhaps unconsciously, you are perpetuating is that 'university is ok for the likes of me', but not for them. If you did not go to university then I apologise for the insinuation.

I remain
A Conservative voter and your obedient servant

Roger Watson PhD RN FRCN FAAN
Editor-in-Chief, Journal of Advanced Nursing
Professor of Nursing, University of Hull, UK
Follow me on Twitter @rwatson1955
Mobile +447808480547
"The plural of anecdote is not data"
Sent from my iPad

Sandy Summers
Prof Linda Shields of James Cook University in Australia sent the email round her distribution list and there were many positive replies but I was especially struck by this one from Sandy Summers (who gave me permission to reproduce here) of the Truth About Nursing organisation in the USA:

We have the same sort of problem in the U.S. Conservatives who think in a very short-sighted way insist on replacing registered nurses with nursing assistants and other technicians, educated at a mere 1-3 months beyond secondary school. They take vital signs, empty bedpans and give bedbaths, all tasks which should belong to registered nurses. Can a tech discern the difference between healthy and ashen color? A normal respiration and dyspnea? A bedpan full of poop or digested blood? Hardly. Yet these data collection tasks are given to people who have not been educated on the human body and how it functions. If it's nursing care, nurses should be doing it. Nursing assistants can't be present in the Benner fashion if they have no idea how to make physiological, social or psychological assessments. They can stand there all day and attempt sympathy, but until they are educated as nurses, they might as well have blinders on and ear plugs in.

And when non-nurses deliver nursing care, among other things, patients go unfed, and not hydrated, as the media has been telling us for years happens commonly in the UK. So if you know nothing about nursing, let's blame nurses! It's easy!  But a lack of decent nursing care isn't caused by bad nurses or nurses with their noses stuck in books--bad and neglectful care is caused by accountants and executives who know nothing about the value of nursing. If they really cared about the patients that they say they care about, they would give nurses adequate staffing--no more than 4 patients on a med-surg floor, about 1.5 in the ICU… And no nursing assistants or techs should have any hands on, assessment or data collection role in patient care. Hahnemann Hospital in Philadelphia, Pennsylvania, U.S. last year went to an all-registered nurse staff. Here's what they said:

The percentage of nurses who said they could complete their work during their shift rose from 37 before the pilot to 74 after, reducing overtime payments. Fewer patients got bedsores or had trouble with blood thinners. The number of emergencies at the bedside was nearly halved - a sign, Halter believes, that nurses were identifying problems before they got out of hand. Fewer patients fell. Patient satisfaction rose, especially with pain control.

All hospitals should follow this example--world wide.

So let's all of us nurses pledge to the profession that next time one of these politicians starts blaming inadequate nursing care on nurses that we reach out to the media and tell the public--not just the politician who made the ignorant comment--tell the world that the real people to blame for inadequate nursing care are greedy, stingy, short-sighted and ignorant politicians and executives. Want good nursing care? Then give us registered nurses, and enough of them or you take the blame. We should start taking them to court for genocide, really, for the decisions they make to withhold nursing care is taking the lives of millions around the globe every year.

Sandy Summers, RN, MSN, MPH
Founder and Executive Director
The Truth About Nursing 
203 Churchwardens Rd.
Baltimore, Maryland 21212-2937  USA  
phone 1-410-323-1100
fax 1-410-510-1790

The Truth About Nursing is a 501(c)(3) non-profit organization that seeks to increase public understanding of the central, front-line role nurses play in modern health care. Our focus is to promote more accurate, balanced and frequent media portrayals of nurses and increase the media's use of nurses as expert sources. The Truth About Nursing's ultimate goal is to foster growth in the size and diversity of the nursing profession at a time of critical shortage, strengthen nursing practice, teaching and research, and improve the health care system.