Fighting equality disease
November 15, 2009 -- Today the Sunday Times (U.K.) ran a piece by columnist Minette Marrin attacking the government's plan to require that all nurses have a three- or four-year university degree by 2013. Marrin (right) argues that the plan would have "disastrous" effects primarily because it would exclude those who would make "excellent" nurses even though they are "not particularly academic" or "not particularly bright." Evidently, the plan is an example of "equality disease": the misguided effort to extend university education to more people, and to consider as "professional" many jobs that do not merit that exalted status. Marrin actually argues that university degrees inhibit good nursing, because they produce nurses who are not necessarily "too posh to wash," but who are not much good at it, with their heads full of all that irrelevant theory. Nurses should not seek equal status with physicians, she suggests; apparently they should be satisfied to be considered handmaidens. The column is so full of uninformed disrespect that it's hard to know where to begin a response. But we'll try to be professional about it. Nursing is an autonomous profession with a distinct scope of practice built on scientific knowledge. The vast majority of U.S. nurses have college degrees that require three or four years of training, and hundreds of thousands have graduate degrees (i.e., at least six years of university training). Research shows that higher levels of nursing education improve patient outcomes. New physicians have little practical experience, but no one argues that their formal training is wasted. The argument against nursing education is based on the false assumption that nursing is mainly about physical labor and hand-holding. But in an increasingly complex care environment in which physicians and others have graduate degrees, nurses cannot provide expert direct care or advocate effectively for patients without advanced training. Please educate Ms. Marrin about what nursing is and is not.
November 2009 column
The column is headlined "Oh nurse, your degree is a symptom of equality disease." Marrin says the plan to require all National Health Service (NHS) nurses to have university degrees is one of the government's "sillier" ones:
All sorts of people who might make excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone who -- frankly -- is not particularly bright; anyone who has a vocation to care for patients without wishing for the most high-tech training; anyone who is unable to take on a mass of student debt on a nurse's poor pay; any late entrants -- and this at a time when the NHS is desperately short of nurses.
Marrin says she rarely agrees with unions, but
the nursing unions Unison and Unite are right when they say that there is no 'compelling evidence' that degrees for nurses would improve patient treatment.
On the contrary, Marrin believes, there is
a great deal of anecdotal evidence quite the other way: that nursing degrees on a university campus with too little practical hospital experience have recently been producing graduates who are all too often, in the words of one consultant [physician], "a liability on the wards" -- not necessarily "too posh to wash" but often not much good at it, or at the important clinical observations that go with it.
Marrin is quick to assure us that a "demanding degree course" might have value for nurses who are "suited to intense academic and technical study." She says such nurses should and now can get degrees,
though one might argue about the nature of the present courses: more than 25% of nurses already hold a degree.
Apparently, there's no way that many nurses could be bright and academic enough to earn demanding degrees. Indeed,
not all would-be nurses are suited to a university degree; just as people vary hugely, so do nurses, so do the nursing roles they are fitted for and so does the training that suits them best. Plenty of the best bedside nurses are not academic, and much essential nursing work does not depend on the dizziest heights of training. There is more than one way to be a "supernurse", and a degree is not enough.
Endorsing the unions' point that there is a difference between "competence" and "academic ability," Marrin dismisses health minister Ann Keen's "predictable noises" about improving care. Marrin knows that the real reason for the move is
the desire of the Royal College of Nursing and the nursing establishment to raise the status of nursing, and to end the stigma of the "doctor's handmaiden". Nurses -- or rather those who claim to represent them -- want to have the status of professionals, on a level with doctors, and part of being a professional is having a degree. So nurses must have degrees. All of them.
Marrin finds this "obsession with status" depressing because it's just part of a pernicious national desire to lift everyone up, to have half the population attend university. (Horrors.) She recalls the halcyon days of her youth, when only the privileged few could attend university, be considered "professionals," and attain the "concomitantly high social standing." But now the rabble wants to join the party! And the result, obviously, is a dangerous decline in standards, as more and more people (not just nurses) evidently are getting pointless university degrees with no relevance to their menial, unskilled labor.
The other example Marrin cites is a visit she made a few years earlier to a "small day centre for young adults with marked learning disabilities." The staff showed Marrin some work by several of these adults which was to be submitted in support of their applications for a certificate that apparently required a level of literacy Marrin doubted the adults had. The staff admitted that they had provided "support" in the creation of this work, but they argued that the adults had a "right" to a qualification, since "social inclusion in the form of a qualification was more important than the objective value of that qualification."
In Marrin's view, this is all part of the misguided thinking behind the nursing degrees. If half the population should have degrees, why not three quarters, or even everyone? "And so -- why not for all nurses?"
Marrin's column did cause us to have concerns about declining standards, though nursing was not the focus of those concerns. (Marrin herself suggests, with admirable modesty, that even journalists may not deserve to be considered "professionals.") Marrin does not seem to understand the broader educational requirements of modern industrialized societies, which actually need more and more people with advanced training to create and manage all those wacky new gizmos (like the one on which she wrote her column), and fewer and fewer people to haul bricks and plow fields by hand. Increasingly, decent jobs require significant university education. But fortunately our current task is limited to addressing what nursing is and what nurses do.
Nursing is more about thinking than "washing." No one can be an "excellent" nurse unless he is also "bright," because nursing requires advanced health care knowledge and critical thinking. It is a distinct health care science led by thousands of scholars with doctorates in nursing. Nurses must initiate and administer complex treatments, monitor patients for subtle changes in conditions, teach patients how to regain health or live with their conditions, and advocate for patients with a range of other professionals, including physicians. In these ways, nurses save lives and improve patient outcomes every day.
But nurses who lack advanced training or intellect cannot effectively do that work. How does Marrin think nurses make "important clinical observations"--with feminine intuition? People in general may "vary hugely," and we appreciate Marrin's admission that at least some nurses might be "bright" and "academic," but good nurses, like good physicians, cannot vary hugely in every respect. You cannot be a good nurse if you're not bright, or not good at what nurse Rose on Grey's Anatomy memorably termed that "boring science stuff." Of course nursing also requires intimate physical work and good interpersonal skills, but so does medicine, and no one equates that profession with the "non-academic" aspects of the work. Nor does anyone argue that, because new physicians are often clueless about patient care, their extensive formal training is useless or even detrimental. Instead, new physicians gain practical experience through clinical training. So do nurses. In fact, physicians rely on nurses to spend significant time providing them informal training when they are new. Educating physicians too is quite a challenge if you're "not particularly bright."
There is compelling evidence that more nursing education leads to better patient outcomes. A Linda Aiken study found that hospitals at which only 10% of the nurses had bachelor of science degrees (BSNs) had twice the mortality rate of hospitals with 70% BSNs. A Needleman / Buerhaus study found that increasing the ratio of registered nurses (with 3-4 years of college-level training) to licensed practical nurses (with one year of training) to the 75th percentile in all US hospitals would save 5,000 lives and $1.05 billion in total costs, decrease hospitalization by 1.5 million days, and decrease hospital expenses by 0.5% per year.
But even if there were not such evidence, it is simply common sense--if you understand the complex and demanding work that good nursing actually requires--that a certain level of formal education is required. A three- or four-year university degree is hardly a radical notion. Indeed, in the United States, the vast majority of registered nurses have bachelor's or associate's degrees that require roughly that amount of university training. For Marrin's reference, these degrees are only awarded to those who are actually literate, and no one completes the work for the nursing students so they can feel included. In addition, the entry level education for social workers, physical therapy and pharmacy is a (post) graduate degree, and there is an argument that this is where nursing must eventually end up. Why? Because unbeknownst to some, all of these fields are actually very complex, and they often make the difference between life and death.
Nursing is now a profession, because it is a self-governing field with its own distinctive scientific knowledge base and a unique scope of practice. Nurses train and manage nurses, and they are governed by distinct legal and ethical standards. Marrin seems to suggest that many nurses, unlike their representatives, are not so troubled by the thought of being physician handmaidens and have no real desire to be respected as equals. Common sense and our decades of experience suggest otherwise.
In fact, this is not Marrin's first foray into the supposed simplicities of nursing education. In August 2009 the U.K. press carried many items about a recent report detailing distressing cruelty and neglect by some nurses. One of these items was an August 30 Times column by Marrin headlined "Fallen angels: the nightmare nurses protected by silence." In it she argued that the problems stemmed not from a lack of resources but from a "cultural collapse" within nursing. Marrin attributed that decline partly to efforts to increase nurses' "professional status with a university degree," which had led them away from "old-fashioned bedside" care. But of course, good bedside nursing requires advanced university-level training, just as it requires compassion and physical skills.
It seems more likely to us that the weakness of nursing in many current settings, and the apparent lack of compassion some nurses display, is due less to a misplaced desire to attain higher status than it is to the weakness and lack of resources that are the natural results of low status and the contempt Marrin herself displays. Marrin recognizes that U.K. nurses receive "poor pay" and suffer from the handmaiden "stigma." She just seems to think nurses should be happy with all that. Maybe such forbearance would keep the "angels" from "falling." But when a profession is not respected by society, when it is subject to abuse and neglect, it is more difficult for practitioners themselves to respect it.
Please help us educate Ms. Marrin about the nature of nursing.
When you have finished, please post it in the comments section on her blog. Thanks very much!