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An all-graduate profession: taking nursing to the next level

The UK government set out its plan for the future of nursing in its 2006 report, Modernising Nursing Careers.1 This document, with an introduction by Chief Nursing Officer for England, Christine Beasley, outlined the direction it was hoped the nursing profession would take, with a focus on expansion of skills, increased responsibility for nurses across primary and secondary care. The report stated nurses should 'work as leaders and members of multidisciplinary teams inside and outside hospital, and across health and social care teams.'

Then, in 2009, former Health Minister, Ann Keen announced that, from 2013, all nurses will need to be educated to degree level to enter the profession. She said, "Nurses are the largest single profession within the health service, and are critical to the delivery of high-quality healthcare. Degree-level education will provide new nurses with the decision-making skills they need to make high-level judgements in the transformed NHS."

The news came as no surprise to many who had been expecting the government to raise the level of education for nurses and the requirement to complete further study beyond the original nurse diploma.

However, the announcement caused heated discussion among health professionals and the public, and debate began immediately about the reasoning behind the decision, and the validity of asking nurses to train to degree standard before they even begin to face the practicalities of day-to-day life on the ward or at the GP surgery.

Until now, nurses have been required to study for a diploma in order to register with the Nursing and Midwifery Council (NMC). Both diploma and degree courses take three years to complete, with around half of the time spent gaining practical experience and half on academic work. The diploma course comprises 72 credits at level 4 and 168 credits at level 5, whereas degree students complete 120 credits in each year of the course, at level 4 in year one, level 5 in year two and level 6 in year three. Nurses who are already registered and hold a diploma have the option of taking top-up courses to complete a degree to keep their qualifications up to date if they so wish.
Interestingly, comparing the UK with the rest of the world, most European countries, as well as Australia and New Zealand, offer a degree-only route to nurse registration. The US, Canada and Japan offer alternative routes, such as a three-year diploma.2

The arguments against nursing as an all-graduate profession can be broadly categorised into concerns that:

  • Some who wish to enter the profession will be put off by the demands and requirements of a degree course.
  • Degree courses will attract fewer students from ethnic minorities who feel excluded from the British education system.
  • Degree nurses will be less willing to undertake basic clinical care, such as washing, feeding and personal care.

These views have been expressed to Nursing in Practice by nurses currently employed by the NHS, who feel that the particular skills and experience they have gained during their career, and who registered with a diploma, will be less valuable. NiP reader, Cathy Beresford, a Diabetes Specialist Nurse from Berkshire, believes that the decision may discourage people from entering the profession.

She says: "Some people who make good nurses are not particularly academic and will be put off by having to study for a degree. Will our pay reflect this additional requirement? I doubt it. Perhaps some people who go into nursing are not ready to do a degree initially, but are happy to go on to do a degree later in their career (as is already the case now).
"I work with several colleagues who are very experienced and skilled nurses who did not go into nursing via a degree programme, but have gone on to gain a degree later in their career."

One of the challenges faced by student nurses may be that they will find balancing academic requirements with the more practical aspects of the training difficult. NiP reader, Sarah Curley, is studying for a nursing diploma in Manchester and hopes to change over to the degree next year.

Sarah believes that studying for a degree won't discourage potential students in the first instance. "If people are serious and dedicated to becoming a nurse I do not see why this would discourage them from entering the profession. Whether you are 'academic' or not, you still have assignments and exams when you enter nursing education."

Looking at the evidence comparing degree with diploma students, Robinson and Griffiths point out that the impact on recruitment needs careful consideration, as some branches of nursing appear to attract larger numbers of students without formal academic qualifications, such as mental health and adult nursing. Mental health nursing also attracts a higher proportion of mature entrants than other subgroups.3

Despite these concerns, the degree requirement has been endorsed by the Royal College of Nursing (RCN) and the NMC. After consultation in 2007-08, the NMC approved plans for the minimum award for pre-registration nursing programmes in the UK to be nursing registration with degree.3 The document outlining the new requirement stated that the following criteria should be met in order to register:

  • Minimum of three years, or 4,600 hours, full-time or part-time equivalent (to be completed in five years full-time, or seven years part-time).
  • 50% theory to practice ratio.
  • Mix of both community and other practice learning sufficient to achieve required outcomes.

There may be those who are against the plans, but many health professionals have expressed the view that this step could help raise the profile of the profession and change the opinion of those who see nurses as 'handmaidens' to doctors' superior academic knowledge.

The University of Southampton announced recently that it will train all its nursing students to degree standard as the first educator in England to move over to an all-graduate programme according to new UK standards.  

Professor Jessica Corner, Dean of the Faculty of Health Sciences, said: "This is an historic moment for nursing - we have been pressing for this for a very long time. From September we will be preparing a new generation of nurses for the NHS.

"Nurses now require a high level of technical competence, clinical knowledge and decision-making skills in addition to their more traditional caring role. By qualifying to degree level, our graduate nurses will have the range of skills they need to deal with the challenges of modern nursing."

The traditional image of the nurse as assistant to the doctor or GP, carrying out basic tasks and following orders, no longer applies and perhaps this decision is representative of a welcome move forward for nurses working across the NHS.
Sarah Curley says: "Degree-educated nurses undertake more modules than diploma students, and this can only be a good thing in terms of equipping the nurse with further knowledge and evidence-based research to enable the delivery of better patient care.

"As a diploma student, I had to make the choice of opting for the diploma because of childcare costs and the bursary helps with this. However, nursing is changing, and roles are becoming more dynamic. Surely studying at degree level will enable better patient care, resulting in more critical thinking to achieve better decisions and outcomes for
the patient."

Andrea Spyropoulos, President of the RCN, and still employed as a nurse herself, strongly believes that nurses should be educated to degree level and that the move will not affect standards of patient care negatively. She also said that the move puts the profession on a level with other countries, and will give nurses academic credibility and the ability to hold their own when it comes to making decisions that are research based.

"I didn't have a degree, I came in as an apprentice when I was 22. During my time as a ward sister I worked with degree nurses and diploma nurses, and within a year there was
no difference in their skill. However, today people expect to go to university. Physiotherapists and dietitians do a degree, so why not nurses? If you want to recruit today's talent, they are going to want to complete a degree."

She called for a career structure that allows healthcare practitioners to make the transition to degree so that people are not trapped because of what is seen as an 'educational deficit' and that will ensure people of all backgrounds have access to degree-level education.

She went on to say, "If you do a diploma, the first two years are identical to what the degree nurses do in terms of academic achievement. It's a short step to level 3, so you can't say that someone who wants to be well educated and rationalise what they are doing detracts from their innate desire to be caring. When you're in uniform no one knows what qualifications you hold. They just see you as a nurse."

It is clear that we face a time of uncertainty and that all nurses will need to work together and learn from their experiences and those of their colleagues - but it remains to be seen what the outcome will be and how the changes will affect nursing and the quality of care given to patients within the NHS.

References

  1. Department of Health. Modernising Nursing Careers: Setting the Direction. London: DH; 2006.
  2. Robinson S, Griffiths P. Scoping review: Moving to an all-graduate nursing profession: assessing potential effects on workforce profile and quality of care. London: King's College; 2008.
  3. Nursing and Midwifery Council (NMC). Confirmed principles to support a new framework for pre-registration nursing education. Available from: www.nmc-uk.org/Get-involved/Consultations/Past-consultations/By-year/Pre...

Your comments (terms and conditions apply):

"As I review this article again, I have a diploma level student sitting in my baby clinic observing. This delightful caring nurse has stated almost word for word what I have highlighted; that the degree student does not want to do nursing duties like
bedpans, making beds etc. She just wants to do the BPs and other such duties that do not 'soil' their hands. As they say, straight from the horse's mouth. Let's get real about this degree business, nursing will go down the pan!" - Pauline Filby

"The likes of Caroline Stephens are the backbone of nursing care and it would be criminal if such nurses, with all their many years of knowledge and experience, were made to go to degree level. Surely the new (ridiculous) idea would be for the future student nurses not inflicted on the 'old' nurse who really know how to nurse" - Pauline Filby

"What about us nurses in our 40s and 50s? Will we be asked to complete a degree on top of our nursing qualifications? Practice nurses gain experience of our jobs over many years as well as the add on diplomas in specialties such as diabetes and asthma. If the NMC want me to have a degree it will be bye bye nursing, hello supermarket and a lot of my colleagues feel the same" - Caroline Stephens

"We need nurses who will NURSE and care for the patient and their basic needs. My friend was recently in hospital and needed a bedpan, as she was confined  to bed post-op. The
'degree' student nurse told her it was not the appropriate time for a bed pan!!!! What utter rubbish, what 'research' do we need to do, into the times that patients need bedpans!! The patients need to know that ANY nurse will help them when they need help - not when they think it is right, or, only when the nursing assistant is on duty. Nurses need to nurse - not to think of themselves on a higher strata of knowledge, so high
they cannot help a patient in the simple but very necessary duty of bedpans" - Pauline Filby, Chelmsford

"Just to put the cat amongst the pigeons, if we had trained nursing assistants and more of them, the NHS would need less graduate trained nurses, more cost-effective and more caring?!" - Michelle Martin, Manchester

"I am a diploma registered nurse with 11 yrs' experience. I agree to a certain degree that there may be some degree nurses who see themselves as too qualified to do basic nursing task. However, in my experience I believe that their unwillingness has more to do with the time-consuming nature of these tasks. Nurses have an ever-increasing demand to complete paperwork, take up roles that doctors no longer want to carry out, and make up for the demise of the previous three-tier nursing system, which comprised nursing assistants, enrolled nurses and registered nurses. I believe that basic tasks should be carried out by nursing assistants as they have more time to give to patients. Time to carry out activities of daily living is essential whilst undertaking these sensitive tasks. I believe nursing assistants should be trained to a higher level and held accountable by registration for their roles. There should also be a higher number of nursing assistants to registered nurses to facilitate this. In my experience because the registered nurse is the one with a registration they find themselves doing everyone's tasks from the cleaners to the doctors as failure to ensure these task are carried out could lead to being struck off. Most nurses would love to do everything, however, there is not sufficient time in one shift. I would like to know if anyone is able to offer any comment on my view. We need degree nurses to make patient care more research based and to take nursing care forward into the 21st century. Unfortunately it is hard to do it with a bedpan in hand" - Angela Oji, Manchester 

"I read with interest the article. If ALL nurses are degree status then hopefully they will have to give out bedpans and do general normal nursing duties, or it will be left to the old minions waiting for retirement!! My experience of many degree nurses, is their heads are so full of excess knowledge they are neither use nor ornament and come out with statements like 'I am a degree nurse, I do not do menial tasks like bedpans etc.' Heaven help the patients of the future, the scary thing is I might end up being one of them! Back in the good old days of matrons!! I remember with deep affection the matron at the hospital where I was training who walking down the ward
with a covered bedpan, saw the look on my face!! Stopped in the corridor and said, 'My dear nurse, I might be the matron but I am still a NURSE!' Those were the days - of good care, and nurses nursed" - Pauline Filby, Chelmsford

"... and yet today, 3 large NHS trusts are failing to provide basic care for their elderly patients! I wish someone would explain why a graduate profession will stop this happening! In my opinion - its the cause of poor care" - Carolyn Gill, Devon

"If all nurses are degree level how can we afford the care? We need better trained nursing assistants - in France nursing assistants train for a year - we need people to do 'basic nursing care' and that can't be someone who has done a degree and wants to be paid for their achievements" - Pamela Donaghy

"I understand all the debate on nursing training but I still feel even if the training is degree level the students would benefit from earlier work on the wards at the start of the 3 years, under supervision as part of the team. Practical skills are performed better and have far greater and positive outcomes for the patients by structuring the work and workforce, to include students on the wards early in their training" - Margaret Hughes, Cardiff