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 is...my 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 may...er...lose 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.

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.

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.

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

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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

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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.

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

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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
Cardiff

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