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

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