Let's talk about nursing
- Correspondence to Dr Alison Twycross
Faculty of Health and Social Care Sciences, Kingston University – St George's University of London, 2nd Floor Grosvenor Wing, Cranmer Terrace, London SW17 0RE, UK;
As I write this editorial, I am halfway through a 6-month sabbatical in Canada. During this time, I have been observing the care nurses provide to patients in a children's hospital. I have been impressed with the care provided to children and their families by what is (currently) primarily a graduate registered nursing (RN) workforce. Nursing in England is gradually becoming a degree entry profession. The media has at times suggested that this is a bad thing for nursing and patient care. Caring is fundamental to nursing,1 2 yet over the past few years numerous examples of suboptimal basic care have emerged.3 4 This is before the move to a graduate entry profession. Indeed, my observations here in Canada, where nursing has been a degree entry profession for many years, suggest that concerns about the move to a graduate workforce are a red herring. The problems with nursing have evolved over a number of years and can be attributed to several factors some of which I will reflect on below. However, before doing so, it is worth noting that having a higher proportion of nurses with a degree on a unit has been found to improve patient outcomes.5
Becoming an RN in Canada requires the completion of a 4-year degree. Most nursing courses in the UK are now 3 years in duration. This is despite the fact that the National Nursing Research Unit found some evidence that graduates from 4-year degree programmes had enhanced competencies and that having a higher proportion of 4-year graduates on a unit was associated with better patient outcomes.6 However, I wonder whether doing a 4-year course allows students more time to reflect on what they are learning and thus apply their theoretical knowledge to practice more effectively?
Unlike the UK, nursing students in Canada are responsible for paying their course fees, which are of a similar level to those of other undergraduates, and do not receive a bursary or grant to cover their living expenses. Perhaps having to pay fees and support themselves financially ensures nurses in Canada make a positive decision to enter the profession rather than viewing it as a cost-effective way of undertaking higher education? Obtaining a place on a nursing course in Canada is highly competitive and requires a good grounding in science subjects, with entry requirements similar to that of other degrees. The move to a degree-only profession in England provides an opportunity to reflect on our entry requirements and recruitment strategies considering both the educational and personal attributes (eg, emotional intelligence and empathy) needed in potential nurses.
In the UK, concern is often expressed that nursing students do not spend enough time in placements with courses being half theory and half practice. However, here in Canada students spend far less time in practice. At the local School of Nursing, the first year is spent predominately in university gaining a good theoretical grounding in key subjects, with 2 weeks spent in the skills lab and 3 weeks in clinical practice at the end of the year. During Year 2 Semester 2 and the third year, students spend 2 days a week in the hospital for 5 weeks, followed by a 6-week placement at the end of the academic year. In the fourth year, this increases to 3 days a week in practice and a 10-week placement. This allows students to apply theory to practice as it is learnt. A new graduate I spoke to said:
“We learnt about something on a Monday and were practicing it in clinical practice on Thursday.”
Universities in the UK tend to have blocks of theory followed by clinical placements, which may not provide such an effective way of linking theory to practice.
Another factor which I believe has an impact on quality of care is the number of RNs per shift. There is a plethora of evidence that having an increased number of RNs results in better patient outcomes7 8 concurring with what I have observed during my time in Canada. However, in addition to ensuring that there are appropriate numbers of RNs on each shift, there is a need to ensure there are adequate support workers with clearly defined roles. Too often, in the UK, nurses end up doing a range of administration and house-keeping roles that could be done as well (if not better) by a support worker. Here, in Canada, the unit I have been based on has at least one ward clerk on duty from 0700 to 2300 each day, as well as care team assistants (who have undertaken a certified course) and ward aides (responsible for ordering stocks, preparing rooms for admissions, etc). All these support workers have clearly defined roles. In the UK, the number of healthcare assistants (HCAs) has doubled in the period between 1997 and 2007.9 Despite this, little attention has been paid to what their role should be with evidence suggesting that HCAs often provide a significant amount of nursing care, sometimes with little training.10 Indeed, from time to time HCAs appear to be employed as substitutes for RNs for no reason other than tighter budgets. There is a need for clearly defined roles for each member of the healthcare team, to look specifically at the RNs role and to ensure that appropriate support workers are employed to free them up to provide care.
It is only by talking about nursing and exploring factors that impact on quality of care that we are going to come up with solutions to the current problems. I have put forward a few suggestions here and there are other issues that need considering. However, one thing is clear, nursing becoming an all-graduate profession is not the disaster the media would like us to believe.
Competing interests None.