To degree or not to degree: that is NOT the question for UK nursing

Current UK nurse training should focus on a national curriculum, its content and assessment, and not its categorisation as a degree, says Ann Bradshaw

June 24, 2018

In December 1996, before she became the “Domestic Goddess”, Nigella Lawson wrote in the Times that: “Irrelevant academic qualifications are an insult to nurses – and useless to their patients.” As the Nursing and Midwifery Council publishes new standards for UK nurse education, it is timely to revisit this argument about whether the UK has an adequate nurse preparation programme. 

The Royal College of Nursing Willis Commission, as well as nursing academics such as Hugh McKenna, David Thompson, Roger Watson and Ian Norman in “The good old days of nurse training: rose-tinted or jaundiced view?”, contend that only degrees can prepare nurses. Indeed, they cite a paper by Linda Aiken et al. that nurses with degrees reduce death rates. And they dismiss disagreement as rose-tinted imaginings of a non-existent golden age: only a degree education can make the nurse “analytical, assertive, creative, competent, confident, computer literate, decisive, reflective, embracers of change and the critical doers and consumers of research”. 

While it is not good history to compare nurse preparation in the past with the present because knowledge, skills and requirements inevitably change, it is possible to compare the philosophy behind nurse preparation past and present and raise questions that are still relevant today.  As I have shown elsewhere, from the days of Nightingale, preparing the nurse with a high level of scientific and medical knowledge as well as practical skills was as important as inducting the nurse into the praxis of care and compassion.  This philosophy resulted in 1923 in a national state syllabus and national practical and theoretical examination.

But the national training was lost when nursing leaders persuaded the reluctant Thatcher government to move nurse education into higher education. They were motivated by a desire to increase the status of the profession – not to improve patient care. This was calculated by the National Audit Office in 1992 as £580 million for extra staff to do work previously done by students (now supernumerary) and £207 million to support colleges introducing the new system. One argument used was to improve recruitment, although this was not actually a problem then. It is now.

Since then, there has been the practice of extending the nursing role into medical and even surgical practice. But, as Geoffrey Rivett points out, UK nurse practitioners are not prepared with skills of diagnosis, examination and treatment, like their US counterparts; instead, nurse practitioner courses are philosophical.

So how are nurses now prepared for their own role as well as their expanded role into medical and surgical practice? How does the degree fit them for this? The current Nursing and Midwifery Council standards introduced in 2010 are generic. Each university implements them in its own way with a variety of assessment methods. The Chief Nurse, giving evidence to the Health Committee in 2013 in the wake of the Francis Report did not know, for example, if or where continence care was taught. 

Perhaps it is because of this that the new NMC standards introduced this year list topics to be covered, but these do not include specific diseases, and no details of levels of content, or teaching and assessment methods are given. These standards remain generic. They still lack prescriptive detail despite the Francis Report recommending a national standard of nurse training: “Therefore, nursing training should be reviewed to ensure that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.” However, his recommendation seems to have been lost in the reports that followed. Don Berwick, for example, attributed failures of nursing to short staffing, not to variable standards of preparation.   

Skills of analysis, assertiveness, creativity and so on, delineated by McKenna et al. do not explain what the nurse knows and does. In fact any other degrees could and do espouse similar skills and qualities. And no degree, as I have argued elsewhere, can inculcate the art of nursing – kindness, care and compassion – that Francis found missing in nurses at Mid Staffordshire and which in 2012 the Chief Nurses listed as requirements.  Neither does a nursing degree prepare nurses for an extended medical role, as training is not shared with trainee doctors.

Moreover, as Chris Rust pointed out in Times Higher Education, without shared assessment it is impossible to compare UK degree standards. This clearly relates to the nursing degree, and it calls into question The Lancet study published by Aiken. For in stating that graduate nurses reduce mortality, Aiken et al. do not discuss the comparability and quality of the degrees that these nurses have attained.

Nursing degrees differ not only in the UK but in other countries. North American and many European nursing courses are much more medically focused than those in the UK. So what does the degree contain and how is this measured? How is the knowledge and skill of the graduate nurse tested to ensure, as Francis recommends, a consistent standard is achieved? And, interestingly, how does a modern nursing “degree” differ in the level of knowledge and attainment of nurses prepared under the previous system?  Was my own rigorous training at the Radcliffe Infirmary in 1971 a “degree” in reality if not in name?

So the question is not whether nurses should or should not be prepared with a degree, rather it is the deeper question: What is a nursing degree?

 Ann Bradshaw is a senior lecturer in adult nursing at Oxford Brookes University 

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Reader's comments (18)

This article is rightly getting a lot of attention on twitter. The points made by the author are ill-founded and ignore evidence and pedagogy. There is a general lack of logic in this piece, as well as internal contradiction.
The article's argument is clear, that to label a course of training 'a degree' is not the point, it is the content of the course whatever its label. The article skewers the oft cited Aitken review across the USA, Europe and UK that degree nurses save lives: but since they are so massively variable with no common standard at all, this claim is clearly without basis. And within the UK the nursing degrees vary massively, with only very general aspirational hopes from the NMC, no strict syllabuses. UK courses do lack hard biological science as against the US and Europe. Read the Guardian latest on nurses' testimony. The nurse in 2010s https://www.theguardian.com/society/2018/jun/30/life-as-an-nhs-nurse-in-the-10s says " I work with nurses from Italy, Spain and Portugal – over there, nurses are trained to the equivalent of UK junior doctor level. I learn so much from them, but so many of them want to leave because it’s such a hostile environment. Quite often I get patients going: “Oh, I’m glad you’re an English one.” I tell them people who come here to work are trained better. " As the article argues 'degree or not degree, that is not the question', it is the content that matters. Also this nurse says she is in poverty: when trainee nurses were paid members of staff trained on wards, with blocks top quality clinical courses by specialists, they were in employment, the NHS had a full supply of nurses, and arguably care was far better [ see Francis ]. The Willis Report was a pre emptive strike by the Nurses Union written by Jane Salvage as a kind of MPhil not a forensic gathering of evidence like Francis, so is no evidence for 'degree' labelling. The Guardian nurse also testifies to the NHS plundering other nations for nurses, with indigenous recruitment in free.
I have been a Registered Nurse for the past 26 years and quite frankly the amount of educated idiots coming into this job frankly out weighs any benefits that a so called degree might bring, most academics that I have heard being interviewed regard a nursing degree as not worth the paper it's written on. For the record I started out as an SEN.
Bulleid462 "the amount of educated idiots coming into this job frankly out weighs any benefits" That's a worry. In my own experience, the degree nursing students coming through, and I see many, are extremely dedicated, intelligent and compassionate. I can't think of a single one since nursing became degree entry, that I have not been immensely proud of and who hasn't given me hope for the future of nursing. Unfortunately there is a cohort of nurses who are nearing retirement who perpetuate the paternal, hierarchical view that nurses are doctors' handmaidens who should not be educated. Sound familiar Bulleid462?
No it doesn't sound familiar at all, funny that. As that Art Historian the late Brian Sewell wrily observed, One doesn't need a degree in philosophy to be a gardner when he was asked to comment on whether nurses need to have degrees to nurse, a bit of commonsense really which is what nursing is, hardly rocket science is it?
A nursing qualification is NOT a degree; to proffer that it is simply fails to understand both the Education/Training dichotomy and the purpose of a degree. Ann Bradshaw also totally ignores the point of whether it's appropriate to attempt training in an educational establishment. Until she, or indeed anybody, confronts such things all of this 'discussion' is simply unnecessary.
Well...I agree nurses should have degrees and also continuous assessment and mentorship...I think this happens .Unfortunately the dedication and empathy required can be sadly lacking...an article by an 86 year old lady summed it up....you must forget about yourself! In this day and age the outside pressure is huge...also I do think even a bucket load if commonsense will not make you a Nurse Practitioner, prescriber,clinically competent!!!!
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As one of the people named in the opening section I read this with great interest. I completely agree - and myself and the others named - have long called for a return to a national curriculum for nurses - and a common exit exam at the end as the only way to ensure and compare standards - we are in print on this issue. Otherwise I am not entirely sure what point Ann is making here - does she expect the NMC to state every single thing a nurse should know and, presumably, experience? I hardly think that’s possible. But she’s sure opened the floodgates again to the anti education brigade as evidenced by some of the highly unprofessional comments above. I think the great mistake is the expectation that a nurse should come out of a course and be ready to hit the ground running across the enormous range of specialist areas. It’s frankly impossible these days - they need the skills to be able to learn quickly when they move to new areas. And finally, nurses moving into diagnostic and prescribing roles do not learn that philosophically; they have to achieve (I think) 90% in the nurse prescribing exam and spend months of consultant supervised practice before diagnostic skills are assumed safe. The bigger problem here is that the NMC refuses to engage with registering this level of practice.
It's not helpful to label contributors to this debate in pejorative terms; 'anti education' I'm not, 'highly unprofessional' I'm not ... just accept that there are souls in higher education who don't share your beliefs and they are entitled to say so. Additionally, I simply fail to understand why it's unreasonable to expect a graduate nurse to hit the ground running after a University has, de facto, provided him/her with a licence to practise, by awarding him/her with one of their degrees. If the University hasn't provided her/him with such a licence then the process of educating/training that student is flawed and must be questioned. In it's entirety the training of a nurse should be about what they can do in the work place after they have graduated. If the Nurse is not ready to deal with any part of the complexity of the Nursing profession, then the University has failed him/her. At the very least, any training establishment should at least enable the trainee to provide a prima facie case, to would be employers, for further training and further testing; as in other noble professions.
Highly unprofessional am I, really. Coming from a so called academic with a mit mop degree I will take that as a compliment. 26 years as a Nurse with both second level and first level qualifications, yeh right whatever....
Since the requirement for a degree has prevented so many young people from becoming nurses, the NHS has embarked on a barbaric campaign to steal cheap trained nurses from poor countries. WHERE THEY ARE DESPERATELY NEEDED. Meanwhile, poor British people are denied a job and go on the dole. The whole programme is utterly indefensible.
I think Ann's made a very good argument for creation of a national curriculum if not then at least a consideration of comparability in assessment standards. She is right in aiming her criticism at the 1980-90's push for 'status' which drove the wholesale privatisation of NHS schools of nursing. Now each university provider assesses differently and there's little comparability over the product. This may have worked in fields like medicine because there's a clinical academic career route, but that failed to materialise for nursing when the universities incorporated the nursing schools. This is what happens when you sell off a national asset with no effective control: the 'brand' eventually suffers. The 'British SRN' as a gold standard eventually became sullied and no longer garnered any global cachet because it's become meaningless. Fancy the chief nurse not knowing about the nursing curriculum? That speaks volumes about where the profession is today which is bringing back two tier registration because it's seen as a cheaper alternative not because it'll be effective. These are important points that Ann raises which many would wish to ridicule and trivialize but which won't easily go away.
It's unfortunate to read about a Professional Qualification being referred to as a 'Product' and a 'Brand'. Using such references reveals how Universities have contaminated those qualifications which were, until very recently, well understood and which were rightly adorned those who were trusted practitioners in the field.
It would also be good to note the wider context of discussion of universities and degrees, see eg the Reform research document recently produced, including the relationship to professional bodies such as the GMC, Law Society etc. Also Ann's article refers to the issue raised by Chris Rust in Times Higher Education, that without shared assessment it is impossible to compare UK degree standards. This clearly relates to the nursing degree, and it calls into question The Lancet study published by Aiken et al, which fails to discuss the comparability and quality of the degrees that these nurses have attained. There is now a very real fall in good quality recruitment, so the very expensive system is alienating women from a crucial profession.
Well done Anne! Some of the responses to the points you raise are sadly predictable as those in ivory tower fight to keep their 'important positions'. To address some of the comments: Please buy '24 hours to save the NHS' by Lord Crisp who was the first CEO of NHS England to find out the politically driven reality of why New Labour/Alan Milburn closed the hospital based Schools of Nursing. Lord Crisp says by 2000 the NHS was in decline. New Labour desperately did not want to loose the 2001 election. The challenge was how to save money . This was the economic solution. The Guardian nurse also testifies to the NHS plundering - brilliant idea - 'modernise', 'breakdown the "outdated barriers", 'liberate nurses from being the "doctor's handmaiden"'. (I just want to clearly state - at no time in my 50year career as a nurse have I EVER been a doctor's handmaiden! The degree nurses must be doing something wrong) Solution - transfer the student nurse training budget from the NHS to the University budget and the nurse pays - justified by the nonsense of 'nurses being doctors handmaidens' which is a hackneyed strapline made up by Bevan when trying to force doctors to be salaried employees in 1948. Milburn resurrected this claim to justify the economic action he wanted take. Sadly the ambitious nurses just mindlessly repeat this nonsense to satisfy their personal ambition Lord Crisp is clear that the decision to make the degree the only route was NEVER based on patient care but on the economic imperative. The game plan was and remains to educate the nurses at their own expense to a point they can replace some of the doctor's functions - much cheaper to replace them on the wards with untrained health care assistants. A disgrace. In case you have not spotted it - all NHS decisions are now driven by money not care - rationing is now alive and well without a national debate. By stealth. The success of the degree must surely be measured by outcomes - the standard of clinical care. Mid-Staffs, Gosport and Leicester clearly show nursing care is appalling. This cannot be justified (as is being tried in an article in this week's BMJ) that nurses are 'too frightened to question doctors'. I developed the 'post-basic department' for the JBCNS courses with Barbara Vaughan at the Oxford School of Nursing attached to the RI then the JR. Sue Pembrey was at the JR. I taught up to the DN. My speciality is Cardiac Surgery - ITU and Anaesthetics. I have an MA (Bioethics) and am currently doing an MA (History of Medicine) - part of the cohort of uneducated dinosaurs about to retire! Some examples of shocking care: My husband (cardiologist) had an emergency quadruple bypass at the JR Oxford. He was a medical tutor and a cardiologist at the JR. The care was shocking. No space for it all. Some examples: his consent form was falsified by the nursing staff - a criminal offence - so it had to redone (after a massive fight with the nurses - fortunately my daughter is a barrister) at 10:30pm with surgery 7am next morning. He was extubated in the ITU at 6:30pm. By 9am the following morning he suffered a cardiac arrest due to the error of the nurse caring for him negligently altering the pacing setting on his pacing box. This standard of care continued until discharge including a hit squad of 3 senior nurses trying to force an early discharge and a newly trained degree nurse refusing to give him morphine because he had changed his mind. Every time we questioned anything I was called into the senior sister's office and given a 'dressing down'. But the most appalling thing I heard in the ITU was when the patient in the next bed crashed, the nurses said 'you can't die now, we have spent so much money on you'! The doctors were great - the nurses terrible. I asked the doctor's on the cardiac post-op ward why it was so chaotic and the nurses so aggressive but incompetent - they said 'we just keep our heads down and hope the consultant will protect us. If there is an error the managers identify a scapegoat, isolate them and destroy their careers.' The power differential between doctors and nurse was definitely in the hands of the nurses. Several of the doctors were planning to leave medicine or the UK because of this level of bullying. I have just been in Charingcross with an 84 year old relative who had a TIA. I sat with him but never saw a nurse in the space of 5 days apart from bringing him his medication. No one check his nutrition or hydration nor did they do so for the other patients in the ward. Hydration post TIA is very important. A nurse left the entire confidential list of patient data including DNARs on his locker which is a serious breach of GDPR. He was supposed to have an LP & MRI. It took me to harass the nurses to act - they refused to call the doctors. The day before he was due to have his LP he was visited by the 'Hit Squad' to force him out of the hospital. I had to help the doctor with the LP as there appeared to no nurse aware that the procedure was going on and they tried to move a patient's bed into our area as the doctor was inserting the spinal needle. The junior doctors were wonderful, caring and clear. What a shame the nurses were so incompetent and uncaring. The other shocking incident in this ward - a young patient with ?colon cancer and confused was about to fall out of bed but the 2 'degree nurses' did not know how to put him back in without pulling out his overfull catheter bag and drips. I had to go and help them. A visit to St Thomas's with my daughter with POTS last year. She was in for 3 days - never saw a doctor or a nurse. When we asked the nurses what the care plan was, none of them seemed to know - 'not my patient'. One nurse in charge said 'you are ill so you must just wait until someone comes'. For 3 days! Just depressing for those of us who were used to providing high standards of care. My granddaughter was admitted to Chelsea & Westminster last year with a febrile seizure to the Paed HDU. Once stabilised, the nurses failed to ensure the 18 month old was appropriately fed or given fluids. I arrived and found her being fed 'pasta' as no nurse had noticed this is what her parents thought was ok. I have been running a cardiology practice in the private sector until 2015 and have watched this abysmal level of care. Under the apprenticeship model of training, as the nurses were continuously working in the clinical area, they were totally competent to 'hit the ground running'. We were expected to do that as students when I trained in South Africa and were competent to run 50 bed wards as 3rd year students. It is utterly depressing that, because my colleagues in the School of Nursing wanted to 'enhance their 'professional status' - demanding the right to admit, discharge, prescribe etc drank the KoolAid and against the expressed position of the majority of nurses, agreed with a politically driven policy of nurse education. The mantra in 1980 was 'in order to be respected we must become a "Research Based Profession" otherwise we will never be "respected" or gain the positions we want'. Forget patient care. Most of those pushing for this change had failed to get into medical school and resented this. "Unfortunately there is a cohort of nurses who are nearing retirement who perpetuate the paternal, hierarchical view that nurses are doctors' handmaidens who should not be educated". This has to be the most ridiculous, uneducated, extraordinary and discriminatory statement I have ever come across. Unlike degree nurses, Pre-degree nurses were clinically competent so did not need extra training. What a shame this is not true for the degree nurse. The degree only option was politically driven aided by an ambitious and flattered RCN. Every nurse I have worked with who trained before 2002 is horrified and sadden by the lack of clinical competence of the degree nurse with the resulting negative impact on patient care. The other myth is that the requirements of a nurse are to 'advanced and technical' that they have to have a degree. This is complete nonsense. What needs to be done to rectify this state of affairs needs discussion. This is a national disgrace. Finally the point of poaching the trained nursing stock from developing countries is a national disgrace and Milburn criticised this practice only to change his mind a year later. I am a South African. My husband and I worked for 2 years in Baragwanath Hospital, Soweto and know vital it is for SA to retain their nurses which SA have paid for. The UK govt have not recompensed the SA govt.
USA nurse anesthetist here ( how can you afford not to have us in UK?) but this thread closely approximates the sebate in US. I would like to see both spheres if training represented in nurse education as a few ivy league schools used to do it here. Two years of pre-nursing dine anywhere followed by 3 years if hospital based training (very inexpensive). Thus us the best if both worlds and allows people if modest financial means to get an education. These atudents could graduate on Friday and hit the ground running in Monday saving hospitals huge expenses in orientation training. We have about 25% turnover here on the floors which is unmatched by any other profession...exception, Trump White House and imagine how chaotic that workplace must be. Do not agree with posters who would deny university education to nurses. Would you do the same for architects, doctors or teachers? Why do they need liberal arts and hard science and nurses don't?
USA nurse anesthetist here ( how can you afford not to have us in UK?) but this thread closely approximates the sebate in US. I would like to see both spheres if training represented in nurse education as a few ivy league schools used to do it here. Two years of pre-nursing dine anywhere followed by 3 years if hospital based training (very inexpensive). Thus us the best if both worlds and allows people if modest financial means to get an education. These atudents could graduate on Friday and hit the ground running in Monday saving hospitals huge expenses in orientation training. We have about 25% turnover here on the floors which is unmatched by any other profession...exception, Trump White House and imagine how chaotic that workplace must be. Do not agree with posters who would deny university education to nurses. Would you do the same for architects, doctors or teachers? Why do they need liberal arts and hard science and nurses don't?

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